In February, upon introducing the Family Smoking Prevention and Tobacco Control Act, Rep. Henry Waxman (D-Calif.) said the legislation “would give FDA broad powers to regulate tobacco products and protect public health.”
In 2004 Sen. Hillary Clinton (D-N.Y.) urged us to think about children’s entertainment “from a public health perspective.” In that light, she said, “exposing our children to so much of this unchecked media is a kind of contagion,” a “silent epidemic” that threatens “long-term public health damage to many, many children and therefore to society.”
In 2003 Surgeon General Richard Carmona, declaring that “obesity has reached epidemic proportions,” offered “a simple prescription that can end America’s obesity epidemic”: “Every American needs to eat healthy food in healthy portions and be physically active every day.”
In 1999 Thom White Wolf Fassett, general secretary of the United Methodist General Board of Church and Society, applauded the work of the National Gambling Impact Study Commission, saying its report “uncovers the hidden epidemic of gambling addiction.” Later that year, two addiction specialists, David Korn and Howard Shaffer, published a paper in the Journal of Gambling Studies calling for “a public health perspective towards gambling.”
What do these four “public health” problems—smoking, playing violent video games, overeating, and gambling—have in common? They’re all things that some people enjoy and other people condemn, attributing to them various bad effects. Sometimes these effects are medical, but they may also be psychological, behavioral, social, or financial. Calling the habits that supposedly lead to these consequences “public health” problems, “epidemics” that need to be controlled, equates choices with diseases, disguises moralizing as science, and casts meddling as medicine. It elevates a collectivist calculus of social welfare above the interests of individuals, who become subject to increasingly intrusive interventions aimed at making them as healthy as they can be, without regard to their own preferences.
This tendency to call every perceived problem affecting more than two people an “epidemic” obscures a crucial distinction. The classic targets of public health were risks imposed on people against their will, communicable diseases being the paradigmatic example. The more recent targets are risks that people voluntarily assume, such as those associated with smoking, drinking, eating junk food, exercising too little, watching TV too much, playing poker, owning a gun, driving a car without wearing a seat belt, or riding a bicycle without wearing a helmet. The difference is the one John Stuart Mill urged in his 1859 book On Liberty: “The sole end for which mankind are warranted, individually or collectively, in interfering with the liberty of action of any of their number is self-protection.…The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant.” Mill’s “harming principle” is obviously important to libertarians, but public health practitioners also should keep it in mind if they do not want to be seen as moralistic busybodies constantly seeking to expand the reach of government.
Under Mill’s principle, there is a strong case for government intervention to prevent the spread of a deadly microbe, extending even to such highly coercive measures as forcible quarantine or legally mandated medication. The case for intervention to prevent people from placing bets, eating ice cream, or playing Grand Theft Auto is much weaker. It requires demonstrating that such activities harm not only the people engaged in them but other people as well. And although Mill was imprecise on this point in On Liberty, harm to others has to be understood as a necessary but not sufficient condition for government intervention. To justify the use of force, the alleged harm has to be the sort that the government has a duty to prevent—that is, the sort that violates people’s rights.
The Transformation of Public Health
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 medicines for safety. Nowadays it means, among other things, banning cigarette ads, raising alcohol taxes, restricting gun ownership, forcing people to buckle their seat belts, redesigning cities to discourage driving, 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—from their own carelessness, shortsightedness, weak will, or bad values—rather than from each other.
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 Shaw 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 (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 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 were discussing the control of communicable diseases mainly as history. The field’s present and future lay 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,” explained Principles of Community Health in 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. Individual decisions about diet, exercise, stress, and smoking are of critical importance.” Similarly, the 1978 edition of Introduction to Public Health noted 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.” (Emphasis in the original.)
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 rats, mosquitoes, and other carriers. 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, the public health establishment is focusing on those causes and the factors underlying them. Having vanquished most true epidemics, it has turned its 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. In the introduction Joseph Califano, then secretary of the Department of Health, Education, and Welfare, warned that “we are killing ourselves by our own careless habits” and 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.
Healthy People drew on a “national prevention strategy” developed by what is now the U.S. Centers for Disease Control and Prevention (CDC). 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 eight different centers, only two of which deal with the control of infectious disease. The National Center for Chronic Disease Prevention and Health Promotion, for example, includes the Office on Smoking and Health and the Division of Nutrition and Physical Activity.
The CDC’s growth can be seen as a classic example of bureaucratic empire building. Although it is easy to dismiss public health’s ever-expanding agenda as a bid for funding, power, and status, 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. Contrary to the impression left by all the warnings about a “methamphetamine epidemic” that is supposedly sweeping the country, or by CDC maps that show obesity spreading like a plague from state to state, 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.