The Tyranny of Public Health

(Presented at the Annual Meeting of the Association of American Physicians and Surgeons, Raleigh, NC, October 1, 1998)

Last spring, when the tobacco companies said they would no longer cooperate with the effort to pass an 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."

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.

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."

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." 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."

Public health 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, banning cigarette ads, raising alcohol taxes, restricting gun ownership, forcing people to buckle their seat belts, and making illegal drug users choose between prison and "treatment." 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 extent of the shift can be sensed by leafing through a few issues of the journal put out by the American Public Health Association. In 1911, when it was first published, typical articles included "Modern Methods of Controlling the Spread of Asiatic Cholera," "Sanitation of Bakeries and Restaurant Kitchens," "Water Purification Plant Notes," and "The Need of Exact Accounting for Still-Births." Issues published in 1995, when I started researching For Your Own Good, offered articles like "Menthol vs. Nonmenthol Cigarettes: Effects on Smoking Behavior," "Compliance with the 1992 California Motorcycle Helmet Use Law," "Correlates of College Student Binge Drinking," and "The Association Between Leisure-Time Physical Activity and Dietary Fat in American Adults."

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, 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 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.

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.