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.
Healthy People noted that "formidable obstacles" stand in the way of improved public health. "Prominent among them," it said, "are individual attitudes toward the changes necessary for better health. 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." In other words, people engage in risky behavior because they don't know any better. Once they realize the risks they are taking, they will change their ways.
But what if they don't? In the case of smoking, self-styled defenders of public health seem genuinely puzzled by the fact that so many people persist in this plainly irrational habit. They insist that people smoke not because they like it but because they were tricked by advertising and enslaved by nicotine before they were old enough to know better. Scott Ballin, former chairman of the Coalition on Smoking or Health, once told me, "There is no positive aspect to [smoking]. The product has no potential benefits….It's addictive, so people don't have the choice to smoke or not to smoke."
Hence smokers who acknowledge the risks of their habit but cite countervailing rewards are dishonest or deluded, displaying the classic defense mechanisms of rationalization and denial. The sociologist Anne Wortham, herself a smoker, says tobacco's opponents believe that if you smoke, "you are in a state of false consciousness, because you are not aware of what is in your interests. It's the refusal to acknowledge people's capacity to make choices. You just define them out of the discourse. 'Addiction' says they can't even talk about their own likes and dislikes. We can decide for them."
Public health specialists are used to dictating from on high, because their field developed in response to deadly threats that spread from person to person and place to place. Writing in 1879, John Billings put it this way: "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."
Billings was defending traditional public health measures aimed at preventing the spread of infectious diseases and controlling hazards such as toxic fumes. It's reasonable to expect that such measures will be welcomed by the intended beneficiaries, once they understand the aim. The same cannot be said of public health's new targets. Even after the public is informed about the relevant hazards (and assuming the information is accurate), many people will continue to smoke, drink, take illegal drugs, eat fatty foods, buy guns, eschew seat belts and motorcycle helmets, and otherwise behave in ways frowned upon by the public health establishment. This is not because they misunderstood; it's because, for the sake of pleasure, utility, or convenience, they are prepared to accept the risks. When public health experts assume these decisions are wrong, they are indeed treating adults like children.
That tendency is apparent in the rhetoric of the anti-smoking movement. Although more than 90 percent of smokers are adults, the best-funded anti-smoking group in Washington these days is called the Campaign for Tobacco-Free Kids. During this year's debate over tobacco legislation, it ran ads warning that "Every Day, Without Action on Tobacco, 1,000 Kids Will Die Early." The claim conjured up images of fifth-graders dying from lung cancer, 12-year-olds keeling over with heart attacks in the cafeteria, and high school sophomores with emphysema wheezing as they climb the stairs on the way to their next class.
As commissioner of the Food and Drug Administration, David Kessler also tried to infantilize smokers. "Nicotine addiction," he said, "is a pediatric disease that often begins at 12, 13, and 14, only to manifest itself at 16 and 17, when these children find they cannot quit. By then our children have lost their freedom and face the prospect of lives shortened by terrible disease."
The "pediatric disease" label also reflects the public health tendency to pathologize risky behavior, thereby obscuring the role of individual choice. From a public heath perspective, 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 manmade plague," "the global tobacco epidemic." It is something to be stamped out, like polio or scarlet fever.
Treating risky behavior like a contagious disease invites endless meddling. The same arguments that are commonly used to justify the government's efforts to discourage smoking can easily be applied to overeating, for example. If smoking is a compulsive disease, so is obesity. 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 cravings, depression, anxiety, and other withdrawal symptoms.
Sure enough, the headline of a March 1985 article in Science announced, "Obesity Declared a Disease." The article summarized a report by a National Institutes of Health panel finding that "the obese are prone to a wide variety of diseases, including hypertension, adult onset diabetes, hypercholesterolemia, hypertriglyceridemia, heart disease, cancer, gall stones, arthritis, and gout." The panel's chairman said: "We found that there are multiple health hazards at what to me are surprisingly low levels of obesity. Obesity, therefore, is a disease."
More recently, the "epidemic of obesity" has been trumpeted repeatedly on the front page of The New 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 obese increased from a quarter to a third between 1980 and 1991. "The government is not doing enough," complained Philip Lee, assistant secretary of health and human services. "We don't have a coherent, across-the-board policy."
The second story, published in September 1995, 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 disease–or, 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 one-third of cancer deaths and most deaths from cardiovascular disease. The lead researcher, JoAnn Manson, said, "It won't be long before obesity surpasses cigarette smoking as a cause of death in this country."
The odds are that you are part of this epidemic, since most of us are fatter than the experts say we should be. According to a 1996 survey, 74 percent of Americans exceed the weight range recommended for optimal health.
If, as Philip Lee recommended, the government decides to do more about our national weight problem, 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 nutritional value." But surely we can do better than that. A tax on fatty foods would help cover the cost of obesity-related illness and disability, while deterring overconsumption of ice cream and steak.
What was once a joke is now a serious policy proposal. Kelly Brownell, a professor of psychology at Yale University who directs the school's Center for Eating and Weight Disorders, has repeatedly suggested taxing foods based on their nutritional content. "A militant attitude is warranted here," he told the New Haven Register. "We're infuriated at tobacco companies for enticing kids to smoke, so we don't want Joe Camel on billboards. Is it any different to have Ronald McDonald asking kids to eat foods that are bad for them?" In its first issue of the year, U.S. News & World Report included the idea of a junk food tax on its list of "16 Silver Bullets: Smart Ideas to Fix the World."
Of course, a tax on junk food would be paid by the lean as well as the plump. 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.
If this idea strikes most people as ridiculous, it's not because the plan is impractical. In several states, people have to bring their cars to an approved garage for periodic emissions testing. There's no logistical reason why they could not also be required to weigh in at an approved doctor's office, say, once a year, and report the results to the Internal Revenue Service for tax assessment.
Though feasible, the fat tax is ridiculous because it's an odious intrusion by the state into matters that should remain private. Even if obesity is apt to shorten a person's life, most Americans would (I hope) agree, that's his business, not the government's. Yet many of the same people believe not only that the government should take an interest in whether a person smokes but that it should apply pressure to make him stop, including fines (also known as tobacco taxes), tax-supported nagging, and bans on smoking outside the home.
New York City lung surgeon William Cahan, a prominent critic of the tobacco industry, has explained the rationale for such policies. "People who are making decisions for themselves," he said, "don't always come up with the right answer."
The dangers of basing government policy on this attitude are clear, especially given the broad concerns of the public health movement. According to the textbook Public Health Administration and Practice, "public health is dedicated to the common attainment of the highest levels of physical, mental, and social well-being and longevity consistent with available knowledge and resources at a given time and place." Principles of Community Health tells us that "the most widely accepted definition of individual health is that of the World Health Organization: 'Health 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, then, is a totalitarian government.
In response to such fears, the public health establishment argues that government intervention is justified because individual decisions about risk affect other people. "Motorcyclists often contend that helmet laws infringe on personal liberties," noted Healthy People, the 1979 surgeon general's report. "Opponents of mandatory [helmet] laws argue that since other people usually are not endangered, the individual motorcyclist should be allowed personal responsibility for risk. But the high cost of disabling and fatal injuries, the burden on families, and the demands on medical care resources are borne by society as a whole." This line of reasoning, which is also used to justify taxes on tobacco and alcohol, implies that all resources–including not just taxpayer-funded welfare and health care but private savings, insurance coverage, and charity–are part of a common pool owned by "society as a whole" and guarded by the government.
As Robert Meenan, a professor at the University of California School of Medicine in San Francisco, noted in The New England Journal of Medicine two decades ago, "virtually all aspects of life style could be said to have an effect on the health or well-being of society, and the decision reached that personal health choices should be closely regulated." Writing 18 years later in the same journal, Faith Fitzgerald, a professor at the University of California at Davis Medical Center, observed: "Both health care providers and the commonweal now have a vested interest in certain forms of behavior, previously considered a person's private business, if the behavior impairs a person's 'health.' Certain failures of self-care have become, in a sense, crimes against society, because society has to pay for their consequences."
Most public health practitioners would presumably recoil at the full implications of the argument that government should override individual decisions affecting health because such decisions have an impact on "society as a whole." But former Surgeon General C. Everett Koop–who became famous as a foe of tobacco and now is campaigning against obesity–seems untroubled. "I think that the government has a perfect right to influence personal behavior to the best of its ability if it is for the welfare of the individual and the community as a whole," he writes. Koop thus implies that the government is authorized to judge "the welfare of the individual," and he elevates "the community as a whole" above mere people.
Some defenders of the public health movement have explicitly recognized that its aims are fundamentally collectivist and cannot be reconciled with the American tradition of limited government. In 1975 Dan E. Beauchamp, then an assistant professor of public health at the University of North Carolina, presented a paper at the annual meeting of the American Public Health Association in which he argued that "the radical individualism inherent in the market model" is the biggest obstacle to improving public health.
"The historic dream of public health that preventable death and disability ought to be minimized is a dream of social justice," Beauchamp said. "We are far from recognizing the principle that death and disability are collective problems and that all persons are entitled to health protection." He rejected "the ultimately arbitrary distinction between voluntary and involuntary hazards" and complained that "the primary duty to avert disease and injury still rests with the individual." Beauchamp called upon public health practitioners to challenge "the powerful sway market-justice holds over our imagination, granting fundamental freedom to all individuals to be left alone."
Public health, in other words, is inconsistent with the right to be left alone. Of all the risk factors for disease or injury, it seems, freedom is the most pernicious.