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, discom fort, pain, sickness, death, vice, or crimeand whatever has a tendency to avert, destroy, or diminish such causesare matters of interest to the sanitarian; and the powers of science and the arts, great as they are, are taxed to the uttermost to afford even an approximate solution to the problems with which he is concerned."
Despite this ambitious mandateand the book's impressive length (nearly 1,500 pages in two volumes)--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 such things as 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. "The entire spectrum of 'social ailments,' such as drug abuse, venereal disease, mental illness, suicide, and accidents, includes problems appropriate to public health activity," explains Jack Smolensky in Principles of Community Health (1977). "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." Similarly, Introduction to Public Health (1978), by Daniel M. Wilner, Rosabelle Price Walkley, and Edward J. O'Neill, notes that the field, which once "had much narrower interests," now "includes the social and behavioral aspects of lifeendangered by contemporary stresses, addictive diseases, and emo tional instability."
The extent of the shift can be sensed by perusing a few issues of the American Public Health Association's journal. In 1911, when the journal was first published, typical articles included "Modern Methods of Controlling the Spread of Asiatic Cholera," "Sanitation of Baker ies and Restaurant Kitchens," and "The Need of Exact Accounting for Still-Births." Issues published in 1995 offered "Menthol vs. Nonmenthol Cigarettes: Effects on Smoking Behavior," "Correlates of College Student Binge Drinking," and "Violence by Male Partners Against Women During the Childbearing Year: A Contextual Analysis." The journal also covers strictly medical issues, of course, and even runs articles on traditional public health topics such as vaccination, nutrition, and infant mortality. But the amount of space taken up by studies of social problems and behavioral issues is striking.
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. The major killers included measles, scarlet fever, smallpox, diptheria, whooping cough, bronchitis, pneumonia, tuberculosis, and "diarrheal diseases." Largely because of such afflictions, life expectancy at birth was only 49 in 1900, compared to roughly 75 today, while the annual death rate was 17 per 1,000, compared to about half that today. 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 mosquitos. At the same time, improvements in nutrition and living conditions increased resistance to infection. Although it is difficult to separate the effects of public health programs from the effects of rising affluence and changing patterns of work, there's no question that disease-control efforts have had an important impact on the length and quality of life.
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 ac cepted 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 die of things you can't catch: cancer, heart disease, trauma. Accordingly, the public health estab lishment is focusing on those causes and the factors underlying them. Having vanquished most true epidemics, it has turned its attention to metaphorical "epidemics" such as smoking, obesity, and suicide. Along the way, the public health establishment has become the most influential lobby for ever-increasing government control over Americans' personal choices.
By the late 1930s, with the importance of infectious diseases declining, public health specialists started taking an interest in chronic conditions. "The public health establishment requires an issue that has salience in the public press, outside of the scientific community, in order to maintain support," says Barbara Rosenkrantz, professor emeritus of the history of science at Harvard. "Public health only becomes interesting when there are real problems."
The interest in chronic diseases led to lifestyle-oriented medical research that began in earnest after World War II. The Framingham heart study, a large-scale, long-term project that has helped identify risk factors for heart disease, began in 1948 and produced its first report in the early 1950s. The first influential studies linking cigarette smoking to lung cancer appeared about the same time. Philip Cole, a professor of epidemiology at the University of Alabama, Birming ham, argues that concern about smoking and other causes of non-infectious disease is "very much within the classical tradition of public health, even though it does not speak to the issue of contagion." He distinguishes this interest, manifested in the work of researchers and the recom mendations of physicians, from "a continued effort on the part of government to usurp control of individuals' lives," a trend that worries him.
But the concerns of public health practitioners have a way of influencing public policy. Surgeons general of the U.S. Public Health Service have become official nags, urging us to shape up so we can reach the health goals they have set for the nation. The wide domain of public health allows them to champion whatever causes interest them. C. Everett Koop said we should achieve "a smoke-free society" by the year 2000. Antonia Novello condemned liquor and beer advertising that she found distasteful. Joycelyn Elders pontificated about gun control and mastur bation. The circumstances of Elders's departure and the battle over her successor show that both liberals and conservatives take the top public health job quite seriously.
The key event that elevated the surgeon general's prestige and visibility occurred in 1964, when Luther M. Terry released the report of his Advisory Committee on Smoking and Health. The document, which declared that "cigarette smoking is a health hazard of sufficient importance in the United States to warrant appropriate remedial action," heralded the decline of the U.S. tobacco industry and the beginning of the contemporary anti-smoking movement. It helped put risky behavior at the top of the public health agenda.
The involvement of physicians in the auto-safety movement of the late 1960s and early '70s also helped legitimize the expansion of public health. "The automobile is the etiological agent in an epidemic accounting for some 50,000 deaths and 4 million injuries each year," wrote Seymour Charles of Physicians for Automotive Safety and John States of the American Associa tion of Automotive Medicine in the July 4, 1966, issue of the Journal of the American Medical Association. They cited drunk-driving laws, seat-belt requirements, and other mandated design changes as examples of "preventive medicine." Today, advocates of a public health approach to violence cite the medicalization of traffic accidents as a precedent.
The establishment of Medicare and Medicaid in 1965 reinforced the argument that govern ment should take an interest in the personal habits of its citizens because risky behavior might affect the public treasury. In a 1976 essay commissioned by Time, Dr. John H. Knowles, president of the Rockefeller Foundation, reviewed the rise of taxpayer-funded health insurance and declared that "the cost of sloth, gluttony, alcoholic overuse, reckless driving, sexual intemper ance, and smoking is now a national, not an individual responsibility." Writing in Daedalus the following year, he said, "I believe that the idea of a 'right' to health should be replaced by the idea of an individual moral obligation to preserve one's own healtha public duty if you will."
In 1979, the surgeon general released Healthy People, a report that broke new ground by setting specific goals for reductions in mortality. "We are killing ourselves by our own careless habits," wrote Joseph Califano, then secretary of health, education, and welfare, calling 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 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 recom mended motorcycle-helmet laws and gun control to improve public health.
Healthy People drew on a "national prevention strategy" developed by the U.S. Center for Disease Control (now the Centers for Disease Control and Prevention), an agency whose evolu tion reflects the expanding interests of public health. Established during World War II as a unit of the U.S. Public Health Service charged with malaria control in war areas, it became the Commu nicable Disease Center in 1946. By the end of the 1950s the CDC had acquired exclusive federal authority over communicable diseases. In the 1960s it took on a wide range of projects, including family planning and overseas smallpox control. In the early to mid-1970s it absorbed the Public Health Service's nutrition program, the National Institute of Occupational Safety and Health, and the National Clearinghouse on Smoking and Health. It also took over federal programs dealing with lead poisoning, urban rat control, and water fluoridation. In the late 1970s the CDC drew up a list of its main priorities, the most serious health problems facing the country. The list included smoking, alcohol abuse, unwanted pregnancies, car accidents, workplace injuries, environmental hazards, social disorders, suicide, homicide, mental illness, and stress. Today only one of the CDC's seven "centers" deals with the agency's original task, control of infectious diseases.
A cynic would view the CDC's growth as a classic example of bureaucratic survival: If the problem you were charged with solving starts to get better, find new problems that will continue to justify your budget. 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. Without speculating about motivation, we can ask whether it makes sense to apply the methods of disease control to problems that are not caused by germs. If it doesn't, much of what is done in the name of public health today is seriously misguided.