Doctors' Orders
America seems to be suffering an epidemic of epidemics: smoking, obesity, alcoholism, illegal drug use, suicide, homicide, domestic violence, traffic accidents. All these things, and more, are said to be "public health" problems that should be stamped out like smallpox or cholera. Once concerned mainly with the control of infectious diseases, the public health field has expanded to cover just about anything that can be said to raise the incidence of disease or injury. In the process, the public health establishment has become the most influential lobby for government interference in our personal choices.
The first major American book on public health, published in 1879, dealt 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. "The entire spectrum of ësocial ailments,' such as drug abuse, venereal disease, mental illness,
suicide, and accidents, includes problems appropriate to public health activity," explains 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. Individual decisions about diet, exercise, stress, and smoking are of critical importance."
Another sign of the shift is the evolution of the Centers for Disease Control and Prevention, which originated during World War II as a unit of the U.S. Public Health Service charged with malaria control in war areas. 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.
Public health practitioners argue that they are simply adapting to changing patterns of morbidity and mortality. For the most part, Americans today 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, including smoking, obesity, and the failure to wear seat belts. The new focus implies new "public health" measures. Instead of quarantine, vaccination, and water purification, public health specialists call for higher alcohol taxes, restrictions on cigarette ads, and gun bans.
But treating behavior as if it were a communicable disease is problematic. When public-health specialists tell us that "obesity is a disease," "tobacco use is a disorder which can be remedied through medical attention," or "guns are a virus that must be eradicated," they obliterate the concepts of individual freedom and responsibility. Behavior cannot be transmitted to 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.
Resistance to public health measures is not new. 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 public health perspective, which seeks collective prescriptions that do not take account of individual tastes and preferences, is blind to the possibility that risky activitiesówhether smoking, eating fatty food, or riding a motorcycle without a helmetómight offer benefits that outweigh their hazards. It recognizes one supreme value, health, that cannot be trumped by other considerations.
The dangers of basing public policy on this attitude are clear, especially given the broad concerns of the public health movement. Principles of Community Health tells us that "the most widely accepted definition of individual health is that of the World Health Organization: ëHealth is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.' " A government empowered to maximize "health" is a totalitarian government.
[A version of this article was published in Investor's Business Daily on December 27, 1995.]