Congress should
- cut all funding for the FDA, NIH, WHO, CDC, ADA, and other "public health" bureaucracies.
In the U.S. Constitution "We the People" did not delegate any authority to the federal government to conduct medical research or cure diseases. "Liberty Under God" -- competition and Christian morality -- have combined in the "Free Market" to raise our standard of living to levels unimaginable a few centuries ago. Socialism undercuts Christian morality, competition, and medical innovation.
Public Health vs. The Nanny State
Jacob Sullum
Thank you. In the Spring of 1998 when the tobacco companies said they would no longer cooperate with the effort to pass a federal 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 [precursors] 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 overt, destroy, or diminish such causes, are matters of interest to the sanitarian.”
Despite this ambitious mandate, the public health movement of the 19th and early 20th centuries dealt primarily with the control of infectious diseases. This was accomplished through a variety of measures including improved sanitation, cleaner drinking water, eradication of mosquitoes and other disease carriers, isolation of contagious individuals, vaccination, and the use of antibiotics. Such methods were strikingly successful, dramatically reducing death rates from illnesses such as measles, scarlet fever, cholera, small pox, diphtheria, whooping cough, pneumonia, and tuberculosis.
Nowadays, public health textbooks discuss the control of communicable diseases mainly as history. The field’s future and present lie elsewhere.
One textbook, Principals 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 a much narrower interest, 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, raising cigarette taxes, banning alcohol billboards, 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, food poisoning, contaminated water, and dangerous quack remedies. By contrast the new enemies of public health come from within. The aim is to protect people from themselves rather than from each other. Americans no longer live in terror of small pox 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 today. 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 that 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 risky behavior.
The evolution of the U.S. Centers for Disease Control and Prevention is emblematic of this shift. Established during World War I—do you know that the CDC originally did? What its original mission was?—it was a unit of the public heath service that was charged with fighting malaria in the South. Today, the CDC 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 easier 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. But in doing so, 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 it attempts to control the behavior will be resisted.
In 1979, the Surgeon General issued a report called “Healthy People,” in which he noted that formidable obstacles stand in the way of improved public health. Prominent among them, he 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. Sill 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 risk they’re 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 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 Balin, at the time 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 or not to smoke. Hence smokers who acknowledge the risk of their habit, that cite countervailing rewards are dishonest or deluded, displaying the classic defense mechanisms of rationalization and denial.”
The sociologist Ann 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 that they can’t even talk about their own likes and dislikes. We can decide for them.”
Now Ann Wortham is not the only one to be rebelling. Even after the public is informed about the relevant hazards, and assuming that their 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 can’t help themselves. It’s because for the sake of pleasure, utility, or convenience, they are prepared to accept the risks. When public heath experts assume these decisions are wrong, they are treating adults like children. That tendency is apparent in the rhetoric of the anti-smoking movement. Although more than 90% of smokers are adults, the best-funded anti-smoking group in Washington these days is called the—you know it? Campaign for Tobacco-Free Kids.
During the 1998 debate over tobacco legislation it ran ads—these were on the New York Times op-ed page, maybe you’ve seen them elsewhere—with a headline saying “Everyday Without Action on Tobacco, 1,000 Kids Will Die Early.”
Now I don’t know about you, but I had to read that a couple of times, and it conjured up images of fifth graders dying from lung cancer, 12-year-olds keeling over with heart attacks in the cafeterias, and high school sophomores with emphysema wheezing as they climbed 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.”
Now this label, the pediatric disease label, also reflects the public health tendency to pathologize risky behavior, thereby obscuring the role of individual choice. From a public health 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 man-made 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. 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 withdrawal symptoms. [Laughter] Some can be quite serious. [Laughter]
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, hypercholesterol anemia, hypertriglicerademia, heart disease, cancer, gallstones, arthritis, and gout. The panel’s chairman said, “We found that there are multiple health hazards at what, to me, are surprising low levels of obesity.” Obesity, therefore, is a disease.
So, you got that? If it causes a disease, it is a disease.
Now since then, the obesity epidemic has been trumpeted repeatedly on the front page of the New York Times. One of the first stories came in July, 1994. It was prompted by a study from the National Center for Health Statistics that found the share of American adults who are obese—and that’s really fat for laymen—increased from a quarter to a third between 1980 and 1991.
“The government is not doing enough,” complained Phillip Lee, an assistant secretary in the Department of Health and Human Services. “We don’t have a coherent across the board policy.”
A New York Times story that was published the next year 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 the headline as the jump page put it, “Even moderate weight gains can be deadly.” How would you like reading that over your breakfast?
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 said, “It won’t be long before obesity surpasses cigarette smoking as a cause of death in this country.”
Just this month you may have noticed The Times ran a series of lengthy front page articles reminding its readers that the fat epidemic is still with us and only getting worse.
You are probably part of this epidemic, by the way. Since most of us are fatter than the experts say we should be, according to a survey that was a done a few years ago, three-quarters of Americans exceed the weight range recommended for optimal health.
At the American Obesity Association’s first annual conference held last year in Washington, excessive weight was described as a national emergency, a worldwide epidemic, and a ticking time bomb in the health care system. Surgeon General David Satcher called it “a major public health problem that deserves much more attention than it receives.”
What sort of attention, you might ask?
Well 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 of little nutritional value.
Today, like Kelly Brownell, who I love by the way, because he gives such great quotes, is a professor of psychology at Yale University and he directs the Center for Eating and Weight Disorders at Yale.
People like Brownell have taken up this call for censorship. “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?
Brownell has also suggested taxing foods based on their nutritional content. Foods with a high ratio of calories to nutrients would be taxed heavily. While fruits and vegetables might be subsidized.
In 1998, U.S. News and World Report included this proposal, which it called the “Twinkie tax,” on it’s list of 16 silver bullets, smart ideas to fix the world. And they were not joking.
That same year, The New Republic published an article by Hanna Rosen in which she chided alarmist commentators, like me, I guess, who had criticized the notion of using taxes to encourage better eating habits. “Aside from Kelly Brownell and a couple of other academics,” she said, “Very few were people were taking that idea seriously.” One of them, it turned out, was Hanna Rosen. “It’s too bad Brownell isn’t more popular,” she wrote. The rest of her article was devoted to explaining why a Twinkie tax was not such a crazy idea after all.
Now, a food tax; you’ve probably already perceived this problem. A tax on junk food would be paid by thin people as well as fat people. So it might be more fair and efficient to tax people for every pound over their ideal weight. [Laughter] Now this is a market- based system because it would make the obese realize the cost that they impose on society, and it would give them an incentive to slim down. If they didn’t want to lose weight, that would be okay, they could just pay the tax.
Now if that idea strikes people as ridiculous, it’s not because the plan is impractical. In many states people have to bring their cars to an approved garage for a periodic emission testing. There’s no logistical reason why they could not 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.
Although feasible, the fat tax is ridiculous, because there’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 agree, I hope, that’s his business. That is the fat person’s 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 taxes, taxes support nagging, and bans on smoking outside the home.
New York City Lung Surgeon William Keohane, 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.” [Laughter]
Now the dangers of basing government policy on that attitude are pretty 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.”
Now if that’s not broad enough for you, Principals 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 in danger, 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 at San Francisco, noted in the New England Journal of Medicine a couple of decades ago, “Virtually all aspects of lifestyle could be said to have an effect on the health or well being of society.” And the decision reached that personal choices should be closely regulated.
Writing a few years go in the same journal, Faith Fitzgerald, Professor at the University of California at Davis Medical Center observed, “Both health care providers and the common will now have a vested interest in certain forms of behavior previously considered a person’s private business if the behavior impairs a personal health.” Certain failures of self-care have become, in a sense, crimes against society because society has to pay for the 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. (And I haven’t seen any pictures of him lately by the way, but he was pretty chunky when he was in office. I don’t know if he’s taken care of that or not. And I guess I can say here—I’m not sure if this is too mean to say—Kelly Brownell is pretty chunky too. I don’t know if that’s fair to bring that up, but it’s seems to be like an anti-smoking activist who smokes.)
Koop does not seem to be troubled by the implications of this approach. “I think 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.
Now, some defenders of the public health movement have given this a little more thought, and they explicitly recognized the aims of public health are fundamentally collectivist, and cannot be reconciled with the American tradition of limited government.
One public health professor gave a speech back in 1975, which summed up pretty well the obstacle posed by the tradition of limited government. 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,” he said. We are far from recognizing the principal 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. He 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. Thank you.
Who is "in charge" of preventing widespread starvation in America?
Answer: nobody.
But if Americans all starve to death, what good is "health and safety?"
Why do we need the federal government to oversee "health and safety" if the greater task of preventing ourselves from starving to death is left to the unregulated Free Market?
Consumers will buy health and safety just as they buy food. Businesses will compete to sell it to them.
The lowly housewife pushing her shopping cart through the store has no idea how vast structures of industry have been created and work round the clock, bowing down before her, lavishing aisle after aisle of conveniently-sized hygienically-packaged groceries, along with fresh fruit, vegetables, and meat, at her feet, seeking her approval. These same industrial forces will be marshaled at her bidding to provide health and disease control if she is given the freedom to demand it, instead of government telling her which diseases will be controlled, and which will be subsidized.
next: Socialized Medicine
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