Many people seem to think that that “public health” is a scientific white knight. For sure, many medical experts in the public health movement do have real scientific knowledge, but the science stops there. The rest is essentially a political movement.
The Reason Foundation just published my primer on public health: “Public Health Models and Related Government Interventions: A Primer.” A few excerpts:
“In many respects,” says a major textbook of public health, “it is more reasonable to view public health as a movement than as a profession.”
With its wide definition, ideology, and scope, public health is as much as, or more of, a political movement than a field of scientific inquiry. Elizabeth Fee agrees with “the idea that public health is not just a set of disciplines, information, and techniques but is, above all, a shared social vision.” This hared social vision is not founded on the respect of the preferences of all individuals and an attempt to find social institutions that can best reconcile them, but on the idea that some experts, or perhaps a democratic majority that agrees with them, should impose their values and trade-offs on other individuals in society. The progress of public health appears closely tied to the collectivist ideologies that developed in the 19th century. At the beginning of the 20th century, medical educator Harvey Jordan of the University of Virginia predicted that in light of eugenics and “the general change from individualism to collectivism,” medicine would be transformed into public health, and that physicians would upgrade from “doctors of private diseases” to “guardian of the public health.”
One factor in the drift of public health toward total government care has been a non-scientific conception of society.
The ideological content of the public health movement is visible there: a priori, they believe the issue is a matter of collective choice, that is, of imposing a politically determined opinion and behavior on those who don’t agree, instead of leaving it to individual choices. There is no recognition of the existence of two distinct facets of human activity: it is one thing for science to determine (at least provisionally) what are the health consequences of different actions; it is another thing to impose one course of action on those individuals who would make different trade-offs. In the perspective of this paper, truth is a matter of scientific inquiry; choice is a matter of individual preferences (with some exceptions).
Few economists should fail to see how anti-scientific this ideological movement is in matters relating to society, politics, and economics.
READER COMMENTS
Jon Murphy
Mar 24 2021 at 11:45am
Good stuff, Pierre. I just looked over it briefly but it’s very interesting.
As I was skimming, a thought occurred to me: there seems to be a sharp difference between how “public health” was understood in the times of Adam Smith and John Snow versus the 20th-21st Century understanding. Smith doesn’t directly address public health, but he does have some public health arguments (eg his discussion of party walls in WN). John Snow was obviously a BFD in the mid-19th Century public health world. But both of them seemed to be operating under a very narrow, focused conception of public health. Targeted, precise interventions rather than grand schemes. For example, once cholera was linked to sewage contaminating water supplies, the public health response was to build sewer systems and take water purification actions. These are very precise methods; they were grand in scale (building an entire sewer system under London was a monumental undertaking), but narrow in focus.
Conversely, the actions of public health officials in the late 19th Century-modern times tend to be much more grander in scale and scope. Think the eugenics movement: that tried, under the guise of public health, to reach into the most intimate aspects of people’s lives.
There might be an interesting history of thought paper that explores that change. I imagine it’d actually parallel the change in public opinion that Dicey discusses regarding law in his Lectures.
Pierre Lemieux
Mar 24 2021 at 3:11pm
@Jon: Indeed, I believe that the growing acceptance of the supremacy of collective choices by expert opinion and public opinion (which one was leading is an interesting question) explains much in the evolution of public health. Another interesting question is why didn’t the new microbiological knowledge of the late 19th century (until then, the miasma theory of epidemics, related to spontaneous generation, was universally accepted) did not counter the imperialism of public health. Perhaps the special interests of the new public health experts were, by then, already too entrenched?
Thomas Hutcheson
Mar 24 2021 at 7:13pm
There are different conceptions of “public health.” One might be investigation and possible policy recommendations regarding common health conditions in which those sufferings from the malady have no influence on each other –heart disease and food consumption recommendations/regulations. Another might be conditions in which influence each other socially — a smoker may encourage someone else to take up smooching. Another might be a source of disease that require collective action to remove — shutting down a or regulating the use of a well infected by cholera. Finally we have infectious disease where one person getting vaccinated or wearing masks prevents another person from becoming infected.
All might attract practitioners who would feel that their collective efforts are a “movement.”
Jon Murphy
Mar 25 2021 at 10:22am
That’s my point above: the shutting down the well because of a cholera outbreak is a highly targeted and precise action. The others you list are loose and vague. I’d be willing to bet many of the pre-Progressive Era public health officials would reject many of the methods undertaken today as public health.
Thomas Lee Hutcheson
Mar 27 2021 at 10:48am
Basically, I was trying to be analytic about what “public health” could mean. Each one has different considerations about possible policy interventions.
Pierre Lemieux
Mar 27 2021 at 5:48pm
In my paper, I do describe a wide range of possible models of public health. After two or three centuries of conscious practice, a lot of ideas of what public health should be have already been explored.
Pierre Lemieux
Mar 25 2021 at 12:16pm
Thomas: What you seem to be describing is the total government care model. One section of my paper is devoted to that.
Thomas Lee Hutcheson
Mar 27 2021 at 10:52am
I’m more laying out possibilities for what “public health” could mean than “describing.”
Gregory Rehmke
Mar 25 2021 at 12:16pm
My introduction to public health policy was years ago reading Arrowsmith by Sinclair Lewis. Part of the story is the hucksterism of doctors and medical schools, and part the amazing advances of the infectious disease researchers, the microbe hunters. The novel also had some discussion of public health. I remember a part with a traveling progressive-era public health program, and the speaker is outside smoking between talks and accidentally burns the place down. New science lighting a path to a better future! Journal article from June: “Rereading Arrowsmith in the COVID-19 Pandemic “the story of Martin Arrowsmith, an ambitious early-career physician who finds himself drawn to research but gathers no moss as he tries out roles as a clinician, scientist, and public health specialist,…”
https://jamanetwork.com/journals/jama/fullarticle/2767891
Pierre Lemieux
Mar 25 2021 at 3:45pm
Gregory: I haven’t read Lewis’s novel but the article you link to is interesting. My paper may persuade you that the situation is even worse than the JAMA author suggests.
Gregory Rehmke
Mar 25 2021 at 8:35pm
Pierre, I read your Reason paper and enjoyed it. I’ve been researching aspects of public health for past debate topics. A 2007-2008 debate topic called for increasing public health aid to Africa, so foreign aid and public health. I prepared a study guide for students: Africa: Freedom, Prosperity, and Public Health:
https://economicthinking.org/wp-content/uploads/2016/10/AfricaStudyGuideOct8.pdf
More recently I’ve been fascinated by federal nutrition guidelines and the public health push for low-fat foods and “Food Pyramid” now blamed (by many) for the current obesity/diabetes/heart disease “epidemic.” Public Health agencies in US, EU and UK continue to vilify fat in the diet, especially saturated fat.
And the anti-meat crusade now taken up by environmentalist and animal rights people was (and is still) pushed by Seventh Day Adventists who opposed consuming meat (claiming it caused lust in men). A weird convoluted story that Gary Taubes and Nina Teicholz document in their books, and now are reaching tens of thousands more via online nutrition conference and videos from Low Carb Down Under, Low Carb USA, CrossFit Health, Diet Doctor, LowCarbMD, NutritionCoalition.us and others. And they continue to battle Forks Over Knives and other plant-based diet advocates. I’m guessing you already know more about all this than I do, but I’ve been amazing researching the topic (plus I lost 40 pounds… a lot of heavy-lifting research, I guess). Posts and notes here: https://economicthinking.org/category/nutrition/
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