A couple of decades ago, while researching a book about the anti-smoking movement, I was struck by the way that the concept of "public health" had expanded during the 20th century. Originally focused on communicable disease and other external threats, the field grew to encompass a wide range of voluntarily assumed risks, including those associated with inhaling tobacco combustion products.
"Americans no longer live in terror of smallpox or cholera," I wrote in the January 1996 issue of reason ("What the Doctor Orders"). "For the most part, Americans die 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' such as smoking, obesity, and suicide." I cited the evolution of the U.S. Centers for Disease Control and Prevention (CDC), which began as an anti-malaria project of the Public Health Service during World War II, as a prime example of the ever-expanding public health agenda.
"Treating behavior as if it were a communicable disease is problematic," I noted, since "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."
Such resistance, I argued, is justified, since the government is now trying to protect people from their own choices, as opposed to the reckless behavior of disease carriers, polluters, or purveyors of contaminated food or quack remedies. This broad understanding of public health can justify all manner of paternalistic meddling, leading to a world in which every decision that might raise the risk of disease or injury can be second-guessed by bureaucrats.
Nor is that the only danger posed by public health's totalizing tendencies. As the Ebola epidemic of 2014 reminded us, the threat of communicable disease is not entirely a thing of the past. Last fall the CDC was widely criticized for its initial response to Ebola in the United States, and CDC Director Tom Frieden admitted several crucial errors. It does not seem far-fetched to suggest that a CDC focused on disease control, as opposed to every American's bad habits, would be better at controlling disease.