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But these criteria apply to many phenomena that we do not treat as epidemics, including clothing fashions, recreational trends, rumors, jokes, and political ideas. Clearly, not everything that spreads from person to person is an epidemic.
Presumably, an epidemic has to be something bad. Oddly, however, bad is defined not by the individuals involved but by the epidemiologist. A happy, productive, well-adjusted user of illegal drugs is still sick, still part of an epidemic, even though he doesn't realize it. Alternatively, as former drug czar William Bennett has argued, the moderate drug user is an asymptomatic carriera Typhoid Maryspreading misery to others by setting a bad example, even though he feels fine. (Indeed, by doing well while doing drugs, he is a more serious threat in this regard than the addict in the gutter.) Either way, the user has to be isolated and cured, whether he likes it or not.
To be fair, it should be noted that many public health specialists do not tow the official government line, which defines any use of illegal drugs as abuse. They often acknowledge that prohibition has side effects and that the distinctions made by the law do not necessarily corre spond with the objective hazards of various drugs. Defining drug use as a public health problem, rather than a crime, they tend to support "harm reduction" measures such as legal availability of syringes and needles, the use of medical marijuana, and "treatment" as an alternative to prison.
Still, the medical model has coercive implications, especially if "denial" is understood as one component of the "disease." Smolensky says law enforcement agencies should "ignore the user, since his is a medical problem which requires prevention, therapy, or rehabilitation, and is not a criminal act." This begs the question of what happens when the user resists "prevention, therapy, or rehabilitation."
Obesity. If smoking, alcohol abuse, and illegal drug use can be diseases, surely obesity can. It carries substantial health risks, and people who are fat generally don't want to be. They find it difficult to lose weight, and when they do succeed they often relapse. When deprived of food, they suffer strong cravings and other withdrawal symptoms.
Recently, the "epidemic of obesity" has been trumpeted repeatedly on the front page of TheNew York Times. The first story, which appeared in July 1994, was prompted by a study from the National Center for Health Statistics that found the share of American adults who are overweight increased from a quarter to a third between 1980 and 1991. "The government is not doing enough," complained Assistant Secretary of Health Philip R. Lee. "We don't have a coherent, across-the-board policy." The second story, published last September, reported on a New England Journal of Medicine study that found gaining as little as 11 to 18 pounds was associated with a higher risk of heart diseaseor, as the headline on the jump page put it, "Even Moderate Weight Gains Can Be Deadly." The study attributed 300,000 deaths a year to obesity, including a third of cancer deaths and most deaths from cardiovascular disease. The lead researcher, JoAnn E. Manson, said, "It won't be long before obesity surpasses cigarette smoking as a cause of death in this country."
If, as Assistant Secretary Lee recommends, the government decides to do more about obesitythe second most important preventable cause of death in this country (soon to be the first)what would "a coherent, across-the-board policy" look like? As early as June 1975, in its Forward Plan for Health, the U.S. Public Health Service was suggesting "strong regulations to control the advertisement of food products, especially those of high sugar content or little nutri tional value." But surely we can do better than that. A tax on high-fat foods would help cover the cost of obesity-related illness and disability, while deterring overconsumption of ice cream and steak. Of course, such a tax would be paid by the lean as well as the overweight. It might be more fair and efficient to tax people for every pound over their ideal weight. Such a market -based system would make the obese realize the costs they impose on society and give them an incentive to slim down. Last year I suggested this plan in National Review, and the magazine received a couple of letters from readers who took it seriously. Fortunately, they were outraged; but I can't shake the thought that somewhere in Washington a public health bureaucrat read the item and said, "Hmmm...."
Violence. In Sentinel for Health: A History of the Centers for Disease Control , Elizabeth W. Etheridge notes that CDC Director William Foege encountered resistance when he pushed the boundaries of public health in the late 1970s. "Of all the areas," she writes, "violence was the most controversial and the one the public health community found hardest to accept." The opposition to this idea is not surprising. Even people who are willing to redefine risky habits as diseases may be troubled by the denial of individual responsibility implicit in treating assault and murder like an outbreak of influenza.
Focusing on guns is one way of obscuring the moral issues raised by the public health approach to violence. As Chicago pediatrician Katherine Cristoffel, founder of the HELP (Hand gun Epidemic Lowering Plan) Network, explained in a 1994 American Medical News article: "Gun violence should be treated like polio and tuberculosis and every other epidemic. Guns are a virus that must be eradicated." She drew a parallel with the campaign against smoking: "It is possible to ban guns. There's a precedent in cigarette smoking. Before the surgeon general's report, it was a moral issue, a personal rights issue. But once it was declared a public health issue, there was a dramatic change....Get rid of cigarettes, get rid of secondhand smoke, and you get rid of lung disease. It's the same with guns. Get rid of the guns, get rid of the bullets, and you get rid of the deaths."
This is not merely the opinion of a few wild-eyed activists. The
public health establishment has consistently endorsed stricter gun
control, treating firearms as a "risk factor," a "pathogen," a
"social ill" to be minimized or eliminated. According to
Healthy People, the 1979 surgeon general's report,
"Measures that could reduce risk of firearm deaths and injuries
range from encouraging safer storage and use to a ban on private
ownership. Evidence from England sug gests that prohibiting
possession of handguns would reduce the number of deaths and
injuries, particularly those unrelated to criminal assaults." In
1979 the CDC endorsed the goal of reducing
the number of privately owned handguns, with an initial target of a 25 percent decrease by 2000. In 1992 C. Everett Koop declared violence "a public health emergency" and, in response, en dorsed a national licensing system for gun owners.
Public health research on firearms, much of it funded by the CDC, has attracted a great deal of publicity, generating many of the factoids that supporters of gun control are fond of citing. Consider the claim that "a gun in the home is 43 times as likely to kill a family member as to be used in self-defense." This is based on a 1986 study by Arthur L. Kellermann and Donald T. Reay published in the New England Journal of Medicine. Examining gunshot deaths in King County, Washington, from 1978 to 1983, Kellermann and Reay found that, of 398 people killed in the home where the gun was kept, only two were intruders shot while trying to get in. "We noted 43 suicides, criminal homicides, or accidental gunshot deaths involving a gun kept in the home for every case of homicide for self-protection," they wrote. It's not a good idea, they suggested, to keep a gun at home.
But since Kellermann and Reay considered only cases resulting in death, which surveys indicate are a tiny percentage of defensive gun uses, this conclusion does not follow at all. "Mortality studies such as ours do not include cases in which burglars or intruders are wounded or frightened away by the use or display of a firearm," they conceded. "Cases in which would-be intruders may have purposely avoided a house known to be armed are also not identified." By leaving out such cases, Kellermann and Reay excluded almost all of the lives saved, injuries avoided, and property protected by keeping a gun in the home.
In contrast with the criminological literature, where scholars on both sides of the issue carry on a lively debate, studies published in the New England Journal of Medicine, JAMA, and other medical or public health journals almost invariably condemn gun ownership and advocate stricter gun control. As with the studies of tobacco advertising, the public health researchers rarely cite scholars from other disciplines, preferring to stay within a field where almost every one agrees that guns are bad.
The public health research on gun ownership, like the research on other kinds of "un healthy" behavior, is driven by the expectation that people will change their ways once they realize the risks they are taking. Healthy People notes that "formidable obstacles" stand in the way of improved public health. "Prominent among them are individual attitudes toward the changes necessary for better health," it says. "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 ." (Emphasis added.) In other words, only those ignorant of the scientific evidence could possibly oppose the public health agenda.
This assumption is central to the public health mentality. Back in 1879, John S. Billings stated it quite candidly: "By some writers, as Wilhelm von Humboldt and John Stuart Mill, it is denied that the State should directly attempt to improve the physical welfare of its citizens, on the ground that such interference will probably do more harm than good. But 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."