Top Priority: Seeking Common Ground in Promoting Public Health

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This first-ever special issue of Priorities examines the most basic premises and goals of our national public health strategy as we approach the 21st century.

We hope you will find this issue provocative. The centerpiece article by Jacob Sullum may startle you; it may cause you to ask, "Why would a mainstream public health group such as ACSH publish an article that challenges the basic premises of modern public health practice?" The answer is that we want to re-energize the profession of preventive medicine by examining our ultimate goals. As the rabbit told Alice when she asked which way to go, "that depends a great deal on where you want to get to."

Do we want to establish a health utopia? Deny mortality? Pursue any or all real or potential threats to our health? Do we want a society consumed with the goal of achieving "perfect" health at any cost-even if it threatens individual freedoms? Are aggregate national health goals more important than individual choices?

We at the American Council on Science and Health have given considerable thought to these questions since our founding in 1977. We have long recognized: (a) that health and safety are not the ultimate goals of life, but conditions that give us the best chance to achieve our goals; (b) that utopian expectations of "Perfect Health"-the title of a book by Deepak Chopra-and absolute safety are unrealistic; (c) that there are always trade-offs to consider in developing public health policies; and (d) that our time and our resources are limited. Our solution: Prioritize! This magazine's name epitomizes that philosophy.

We at ACSH have long emphasized the need to focus on real public health hazards: to keep an eye on those potential new hazards that come under serious scientific scrutiny-and to dismiss from our daily agenda the purely hypothetical hazards. Having done that, we think we have fulfilled our recommended daily allowances for public health.

But in this special issue of Priorities ACSH goes beyond the basic question of setting health priorities. In this issue we examine the stark contrast between the public health challenges we face today and those we confronted in the early part of this century. No longer are we locked in a mammoth struggle with infectious, communicable disease. And no longer is it a straightforward matter of turning off the water coming out of the Broad Street Pump-as it was for Dr. John Snow in his successful 1849 effort to thwart the spread of cholera.

Today, the major preventable killers present themselves in the form of "lifestyle factors"-specific human behaviors that promote premature disease and death. With behaviors, not microbes, as the targets of our public health campaigns, where do we draw the line between appropriate government intervention and appropriate respect for individual choice and personal freedom?

As you will see in these pages, the answers to this question are many and varied-and very much influenced by every individual's own political ideology and philosophy of life. Jacob Sullum views the modern public health profession as being proúp;big government and elitist-in the sense of having an "I know what's better for you than you do yourself" attitude. He sees the public health establishment as being more concerned about society as a whole-as an aggregate bottom line-than about individuals.

Given the increased socialization of our society-a socialization that includes the national pooling of health-care costs in government programs such as Social Security, Medicare and Medicaid, in which costs that may be incurred by individuals are passed on to and paid by others-the public health establishment's argument goes like this: "You must behave in a socially acceptable manner. You must avoid health habits that might make you sick, because society will have to pay for your care. You owe it to society to avoid behaviors that may imperil our health."

The temptation is all too great for public health professionals to offer oversimplified "solutions" to complex public health problems. The constant finger pointing at cigarette advertising as the primary reason people smoke is an example of this oversimplification (I stand guilty on this charge as well). Advertising does, of course, play a major role in getting kids to take up smoking and in keeping smokers hooked. But if cigarette advertising were to disappear tomorrow, we would still have many challenges ahead. Countries that have banned or severely limited cigarette advertising (France, for one) still have some of the world's highest smoking rates.

This issue of Priorities cautions against simplistic solutions as it explores the difficulties of balancing public health considerations against values such as respect for individual autonomy. Different political ideologies may inspire different approaches to promoting and protecting public health, but there are no ideological boundaries to people's susceptibility to public health threats. Whether you are on the left, on the right or in the middle of the road; whether you call yourself authoritarian or libertarian-if you smoke, you are risking lung cancer, heart disease, emphysema and other illnesses.

Unfortunately, some political leaders who hold tightly to inflexible ideologies show a remarkable insensitivity to our shared vulnerability. New York Times commentator Frank Rich explored one aspect of this phenomenon in a recent column-a column reprinted in this issue of Priorities. Many Republicans have come to be opponents of any and all solutions to the pandemic of cigarette-related diseases, allowing Democrats to assume-for better or worse-the leadership role in confronting smoking as the cause of half the premature deaths-500,000 in all-in the United States each year.

Holding fast to a passionate ideology of defending individual freedom and opposing government solutions to problems, Republicans have dismissed smoking as purely a "liberal" issue. Worse yet, some Republicans appear to be aligned with the tobacco companies themselves. This is a no-win situation, both for the Republican Party itself and for the people it represents.

Surely, addressing smoking as the single largest factor contributing to total years of life lost in the U.S. ought to be a nonpartisan issue. Surely, public health professionals and defenders of individual liberty like Jacob Sullum can work together to find common ground. Surely, we can all cooperate in developing ways to reduce mortality related to lifestyle factors-factors that include not just smoking, but alcohol and drug abuse, firearms abuse, unsafe sexual practices, imprudent dietary practices, sedentary lifestyles and the failure to use lifesaving technologies such as seat belts and smoke detectors. Freedom, after all, is ultimately enhanced, not threatened, by good health and safety.

(From Priorities Vol. 8, No. 2, 1996)