KEY TERMS
Centers for Disease Control and Prevention (CDC)
Sexually transmitted disease (STD)
The mission of public health as defined by the Institute of Medicine report, The Future of Public Health—“fulfilling society’s interest in assuring conditions in which people can be healthy”1(p.40)—is very broad. The conditions include many factors that might not normally be thought of as relevant to public health. For example, the factor most significant in determining the health of a community is its economic status: People with higher incomes tend to be healthier for a variety of reasons. This expansive view of public health is not new. Winslow’s 80-year-old definition specifically includes as part of public health’s role, “the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health.”2(p.1)
Indeed, the early history of U.S. public health was closely tied to social reform movements. In addition to sanitary science and public hygiene, 19th-century reformers campaigned for improved housing, trade unions, the abolition of child labor, maternal and child health, and temperance. Winslow thought of public health as a military-style campaign and wrote of “whole populations mobilized for the great war against preventable disease.”3(p.27)
Public health can be viewed as a broad social movement. Dan E. Beauchamp, a noted public health philosopher, has written that “public health should be a way of doing justice, a way of asserting the value and priority of all human life.”4(p.8) In an influential 1974 paper entitled “Public Health as Social Justice,” Beauchamp calls on public health to challenge the ideology that prevails in the United States, an ideology that he calls “market justice.” Market justice, he writes, emphasizes individual responsibility, minimal obligation to the common good, and the “fundamental freedom to all individuals to be left alone.”4(p.4) Under market justice, powerful forces of environment, heredity, and social structure prevent a fair distribution of the burdens and benefits of society. Social justice, on the other hand, suggests that minimal levels of income, basic housing, employment, education, and health care should be seen as fundamental rights. According to Beauchamp, “The historic dream of public health that preventable death and disability ought to be minimized is a dream of social justice.”4(p.6)
Political conservatives have tended to resist this broad vision of public health. They would prefer to limit public health to a technical enterprise focused on controlling communicable disease or as a safety net that provides medical care to the indigent. This restricted view of public health was encouraged by physicians, concerned about government encroachment on their economic and professional independence; their political power helped to limit federal health funding in the 1930s and 1940s to programs, run by local health departments, which were narrowly focused on providing services for child health, venereal disease control, tuberculosis, and dental health.
Concerns about health threats from environmental pollution that arose in the 1960s were addressed independently of the traditional public health system, and separate agencies were set up to deal with them. Similarly, social problems such as homelessness, drug abuse, and violence were not thought of as public health problems, although they had adverse health consequences. It was this fragmentation of public health that led the Institute of Medicine committee to conclude in 1988 that public health was “in disarray”1(p.19) and to affirm the comprehensive view of public health expressed by Winslow and Beauchamp.
The broad view of public health’s scope generates considerable controversy in America’s individualistic, market-oriented society. The notion that government has an obligation to provide healthy conditions for citizens who are unwilling or unable to provide such conditions for themselves—and indeed to provide medical care for those who need it, as most other industrialized countries do—has often been attacked as socialist. Conservative politicians have won office by campaigning against taxes, starving governments of funds that could provide health services for all. Many Americans reflexively oppose being told what to do and resist the idea of governmental restrictions on their behavior even when the intent is to protect their own health and that of others. Moreover, many health problems have their roots in unhealthy behaviors that are so personal and intimate that moralists oppose even discussing them. Three issues—economic, libertarian, and moral—tend to come up repeatedly in any debate over public health actions or activities.
Economic Impact
Most public health measures have a negative economic impact of some kind on some segment of the population or on some industry. Consequently, any new proposal for a public health regulation is likely to inspire opposition from some quarter, on the grounds that it might cost jobs, add to the price of a product, or require a tax increase. It might also cut into a company’s profits. Consequently, industries resist change: Milk producers resisted pasteurization, landlords resisted building codes, automobile manufacturers resisted design changes to improve safety. There are several reasons why these conflicts are particularly difficult to resolve.
The difficulty in dealing with the economic impact of public health measures has been illustrated by conflicts with the tobacco industry. Tobacco is clearly harmful to health, causing thousands of deaths and millions of dollars in medical costs annually. Yet, until recently, only mild restrictions and regulations were instituted to discourage use of the product. Tobacco is a major industry in the South, supporting jobs and providing profits for tobacco companies. Cigarette sales also are a significant source of income for many small businesses. Owners of bars and restaurants have fought laws restricting smoking on their premises, fearing that they would lose the patronage of smokers. Politicians are not eager to institute strong public health measures that would have such a major economic impact. Only in the past two or three decades, with the shift of public opinion against the tobacco industry, together with the industry’s need to protect itself against a potentially bankrupting flood of lawsuits by injured smokers, have federal, state, and local governments begun to take serious measures to control smoking.
In many circumstances, controversy arises because those who pay for a public health measure are not the ones who benefit. Environmental regulations such as restrictions on timber harvesting in the Pacific Northwest are regularly under attack because they may cost jobs in the lumber industry, although they may preserve jobs in the fishing and tourist industries as well as contribute in the long term to a more stable climate. Regulations that protect the health and safety of workers may require expensive protective equipment, thus driving up the costs to consumers.
In times of economic difficulty, people are often unwilling to pay short-term costs in order to obtain a benefit in the long term. In both the fishing and lumber industries, stocks have been dangerously depleted, and there is a risk of killing off all the fish and cutting down all the timber, thereby destroying the industries altogether. Yet few workers in the fishing or lumber industries are willing to voluntarily cut back on their own harvests. Companies resist tough pollution control laws even though less polluting technology may lead to a long-term benefit not only for the environment but also for a company’s competitiveness in international markets. This shortsightedness became apparent at a time of high gas prices, when U.S. automobile companies suddenly lost market share and profits because they invested so much of their production into formerly profitable gasguzzling SUVs that Americans could no longer afford to drive.
The costs of public health measures are usually much easier to calculate than the benefits. For example, experts may know the cost of reducing smog in Los Angeles to a level that reduces deaths from lung disease by 10 percent. But how do they calculate whether this benefit is worth the cost? It is very difficult to put a dollar value on life and health. Furthermore, it is often difficult to quantify what the risk really is and how to balance it against other risks. People are concerned, for example, about farmers’ use of pesticides, which may leave toxic residues on fruits and vegetables. Scientists can estimate the health risks the average person faces by consuming that residue. But fruits and vegetables are an important part of a healthy diet. If the use of pesticides were forbidden, the crops might be less abundant, and the price of the produce might rise, perhaps discouraging some people from eating these nutritious foods. Thus, an effort to protect health might have a negative impact on health overall.
Individual Liberty
One of the primary purposes of government is to “promote the general welfare,” as called for in the U.S. Constitution. Health and safety, together with economic well-being, are the major factors that contribute to the general welfare. While the government cannot guarantee health and safety for each individual, its role is to provide for maximum health and safety for the community as a whole. One of the central controversies in public health is the extent to which government can and should restrict individual freedom for the purpose of improving the community’s health.
There has long been general agreement that it is acceptable to restrict an individual’s freedom to behave in such a way as to cause direct harm to others. Laws against assault and murder are found in the Bible and even in the Babylonian Code of Hammurabi, which dates to the 18th century B.C. When the harm is less direct, however, the issues become more controversial. Most controversial are governmental restrictions on people’s freedom to harm themselves.
