(Page 2 of 4)
The question is especially important because public health generally implies government action. That used to mean keeping statistics, imposing quarantines, requiring vaccination of children, providing purified water, building sewer systems, inspecting restaurants, regulating emissions from factories, and reviewing drugs for safety. Nowadays it means, among other things, raising alcohol taxes, restricting cigarette ads, banning guns, arresting marijuana growers, and forcing people to buckle their seat belts. These measures are attempts to control illness and injury by controlling behavior thought to be associated with them. The idea is straightforward: Less drinking means less cirrhosis of the liver, less smoking means less lung cancer, less gun ownership means less suicide.
Whether or not these expectations are justified, treating behavior as if it were a communi cable disease is problematic. First of all, behavior cannot be transmitted to other people against their will. Second, people do not choose to be sick, but they do choose to engage in risky behav ior. 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.
Resistance to public health measures is not new. Such interventions were often criticized, sometimes justifiably, as inappropriate exercises of government power. But 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. The implications of this distinc tion can be better understood by considering a few of the "epidemics" that have taken the place of smallpox and cholera.
Smoking. In the public health literature, smoking is not an activity or even a habit. It is "the greatest community health hazard," "the single most important preventable cause of death," "the plague of our time," "the global tobacco epidemic." The disease metaphor has been used so much that it is now taken literally. The foreword to the 1988 surgeon general's report on nicotine addiction informs us, "Tobacco use is a disorder which can be remedied through medical atten tion." This definition was not always so casually accepted. In the 1977 monograph, Tobacco Use as a Mental Disorder, published by the National Institute on Drug Abuse, Jerome H. Jaffe noted that "a behavior that merely predisposes to other medical illnesses is not necessarily, in and of itself, a disease or disorder....We certainly would not want to consider skiing as a mental disor der, although it clearly raises the likelihood of developing several well-defined orthopedic disorders. Risk taking, per se, is not a mental disorder."
Yet today public health professionals consider smoking itself a disease, something inher ently undesirable that happens to unwilling victims. "Free will is not within the power of most smokers," writes former CDC Director William Foege in "The Growing Brown Plague," a 1990 editorial in the Journal of the American Medical Association . If it were, they certainly would choose not to smoke. As Scott Ballin, chairman of the Coalition on Smoking or Health, explains, "The product has no potential benefits....It's addictive, so people don't have the choice to smoke or not to smoke."
These statements are part of a catechism intended to explain why
so many people continue
to smoke, when clearly they shouldn't. That catechism does not admit the possibility that smok ing might offer some people benefits that in their minds outweigh its hazards. This blindness is inherent in the public health perspective, which seeks collective prescriptions that do not take account of individual tastes and preferences. It recognizes one supreme valuehealththat cannot be trumped by other considerations.
Having promoted smoking from risk factor to disease, the public health establishment now targets alleged risk factors for smoking, most notably cigarette advertising. "If exposure to cigarette advertising is a risk factor for disease," writes Rep. Henry Waxman (D-Calif.) in a 1991 JAMA editorial, "it is incumbent on the public and elected officials to deal with it as we would the vector of any other pathogen." In other words, banning cigarette ads is like draining the swamps where the mosquitos that carry malaria breed. That seems to be the assumption underly ing the Clinton administration's proposed restrictions on tobacco advertising.
The alarm about the danger posed by cigarette advertising is based largely on well-publi cized studies in medical journals that prove less than the researchers' conclusions and accompa nying editorials imply. A typical example is the 1991 JAMA study cited by the Clinton administration. The researchers reported that 6-year-olds were as likely to match Joe Camel with a pack of cigarettes as they were to match the Disney Channel logo with Mickey Mouse. "Given the serious consequences of smoking," they wrote, "the exposure of children to environmental tobacco advertising may represent an important health risk...." But recognizing Joe Camel is not tantamount to smoking, any more than recognizing the logos for Ford and Chevrolet (which most of the kids in the study did) is tantamount to driving.
The same issue of JAMA carried an article reporting that Camel's market share among smokers under the age of 18 increased from 0.5 percent in 1988 to nearly 33 percent in 1991. The authors attributed the change to the Joe Camel campaign and concluded that "a total ban of tobacco advertising and promotions...can be based on sound scientific reasoning." Yet during the period covered by the study, smoking among minors actually fell. So while Joe Camel may have had something to do with the shift in brand preferences (a shift that also occurred in other age groups, though less dramatically), he cannot be blamed for convincing more kids to smoke.
Jean J. Boddewyn, a marketing professor at Baruch College who is skeptical of the alleged link between tobacco advertising and consumption levels, has argued that medical journals are not an appropriate venue for such research. Writing in the December 1993 issue of the Journal of Advertising, he suggests that medical editors and reviewers lack expertise in the area and are too quick to publish articles that reflect badly on the tobacco industry. "How would the [Journal of Advertising's] reputation fare," he wonders, "if it published an article on the health consequences of smoking, after asking only advertising specialists to review it?" Boddewyn also complains that articles on tobacco advertising in medical journals rarely refer to relevant sources outside the public health literature.
Alcohol Abuse. Like smoking, alcohol abuse is considered a disease within the public health field. Community Health (1978), by C.L. Anderson, Richard F. Morton, and Lawrence W. Green, calls alcoholism "an inborn defect of metabolism," while Introduction to Public Health defines it as "the progressive chronic illness characterized by habitual heavy drinking that inter feres with numerous...aspects of an individual's life." This view of alcoholism remains contro versial, but it has a long pedigree, dating back to Benjamin Rush in the 18th century. As Introduction to Public Health concedes, however, "alcohol in moderation appears to do the body no permanent harm."
Nevertheless, heavy taxation of alcoholic beverages is a standard public health prescription for alcohol abuse. Restrictions on sales and advertising are also popular. Advocates of such measures hope to reduce overall consumption of alcohol and thereby reduce alcohol abuse. "The cost of alcohol should be greatly increased by taxation," Community Health recommends. "There is an excellent correlation between a low relative price, high consumption, and high cirrhotic mortality in international comparisons." In fact, it is not clear that reducing overall consumption would have much of an impact on alcohol abuse. It is precisely the people who have the biggest problems with alcohol who would be most resistant to changes in price or availability. Further more, societies or ethnic groups with relatively low drinking rates may have relatively high rates of abuse, and vice versa.
Assuming a tax hike did reduce alcohol problems, it would not necessarily be justified even on utilitarian grounds. Since moderate drinkers far outnumber alcoholics, their foregone pleasure might well outweigh the benefits of less alcohol abuse. As in the case of smoking, the public health paradigm simply ignores this issue.
Drug Abuse. In the early 1970s a debate raged in academic journals about the merits of studying illegal drug use as if it were an epidemic. Critics of this approach noted that illegal drug use is not caught like a virus; it is volitional behavior. Proponents of the disease model said this didn't matter.
Community Health explains: "If drug abuse is seen as a practice that is transmitted from one person to another, it may be considered for operational purposes as a contagious illness. This approach makes it possible to apply to its study the methods and terminology used in the epide miology of infectious diseases. In the epidemiological model the infectious agent is heroin, the host and reservoir are both man, and the vector is the drug-using peer....The disease presents all the well-known characteristics of epidemics, including rapid spread, clear geographic bounds, and certain age groups and strata of the population being more affected than others."