Why is Public Health Controversial Notes

Chapter 2: Why is Public Health Controversial? -Introduction: ● 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. ● Market justice: an ideology that emphasizes individual responsibility, minimal obligation to the common good, and the fundamental freedom to all individuals to be left alone. ● 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. ● Political conservatives 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 poor. ● The notion that government has an obligation to provide healthy conditions for citizens who are unwilling or unable to provide such conditions for themselves has often been attacked as socialist. ● 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. Thus, any new proposal for a public health regulation is likely to inspire opposition from some group, on the grounds that it might cut jobs, add to the price of a product, cut into a company’s profits, or require a tax increase. Consequently, industries resist change. ● The difficulty in dealing with the economic impact of public health measures has been illustrated by conflicts with the tobacco industry. Tobacco causes thousands of deaths and millions of dollars in medical costs every year, but tobacco is a major industry in the South, and cigarette sales 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 smoking customers. It has taken a long time for tobacco regulations to come into effect because of all the resistance met. ● 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, even though they may preserve jobs in the fishing and tourist industries, as well as contribute to a more stable climate in the long term. ● In times of economic difficulty, people are often unwilling to pay short-term costs in order to obtain a benefit in the long term. For example, experts may know the cost of reducing smog in L.A. to a level that reduces deaths from lung disease by 10 percent. But it is difficult to calculate whether this benefit is worth the cost. It is also difficult to quantify what the risk really is and how to balance it against other risks. -Individual Liberty: ● One of the primary purposes of government is to promote the general welfare. Health, safety, and economic well-being are the major factors that contribute to 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. ● 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. However, when the harm is less direct, the issues become more controversial. Most controversial are governmental restrictions on people’s freedom to harm themselves (like seat belt and helmet laws). ● Government restrictions on behavior that causes indirect harm to others is the way to prevent “the tragedy of the commons.” ● Because no individual has the power to control the quality of his or her own personal environment independent of the behavior of his or her neighbors, government action is required to protect common resources such as the air and water that we all share. ● While the U.S. has made great progress in the past 50 years cleaning up air and water through federal legislation, some people are now wondering if the laws have gone too far in restricting the “freedom” to pollute. ● Restrictions on individual behavior are often criticized as “paternalism.” Libertarians argue that the only purpose for which power can be rightfully exercised over any member of a civilized community, against his/her will, is to prevent harm to others. ● The one form of paternalism that is generally accepted is that children and young people can be restricted in their behavior on the basis that they are not yet mature enough to make considered judgments as to their own best interests. ● According to the libertarian view (which has a strong tradition in the United States), it is acceptable to outlaw drunk driving but not drunkenness itself. Similarly, smoking in indoor public places can be outlawed, while smoking itself cannot be regulated in adults. ● Sometimes, restrictions on individual liberty are justified on the basis that their purpose is really to protect others, even if the argument is a bit strained. For example, alcoholics and drug users bring harm to their families and are a nuisance to their neighbors. ● Most public health advocates believe that there are more fundamental justifications for restrictions on individual behavior for the sake of public health. For example, consistent use of seatbelts prevents thousands of deaths and injuries in the population as a whole...while each individual’s choice to take the risk of driving unbuckled may be rational, society’s interest in preventing the thousands of deaths and injuries outweighs the minor inconvenience of obeying the seatbelt law. -Moral and Religious Opposition: ● Public health often causes controversy on moral grounds, most often when it confronts sexual and reproductive issues. AIDS, sexually transmitted diseases, teenage pregnancy, and low birth-weight babies are major public health problems in the U.S. ● The public health approach to these problems includes sex education in schools and the provision of contraceptive services, especially condoms. These measures are often vigorously opposed by members of certain religious groups who believe that this promotes immoral behavior. ● Preaching abstinence has limited efficacy in preventing STDs and unwanted pregnancy. ● AIDS has been a particularly divisive issue because many people with AIDS contracted the disease through gay sex or intravenous drug use. It is commonly believed that education on how to protect oneself against contracting HIV may encourage homosexuality and promiscuous sexual behavior in general. ● Moralism also enters into discussions of alcohol and drug policy. Libertarians could argue against regulation of alcohol and bans on addictive drugs on the basis that consumption of drugs is private behavior that does not directly hurt others. However, most citizens accept the validity of such regulation. ● Trying to legislate morality has often proven to be ineffective, self-defeating, and a threat to liberty, in part because people differ in what they view as moral. When morality is the justification for banning certain behaviors, rational discussion is often impossible because people are very rooted in their beliefs. ● Moral and religious concerns may interfere with scientists’ studying how to prevent the spread of HIV and other diseases and conditions caused by unhealthy behavior. Up to half the deaths in the United States are preventable, many of them caused by unhealthy behavior. A small fraction of the research funded by the government is devoted to understanding why people behave in unhealthy ways and how to encourage them to change these behaviors. This research is highly controversial and is vulnerable to attack by conservative groups. -Political Interference with Science: ● While there are legitimate differences of opinion on how to weigh the competing interests in making policy that affects public health, these decisions should be informed by science to the extent possible. ● The George W. Bush administration was notorious for going beyond previous political practices in manipulating and distorting scientific evidence to fit its political agenda. ● The Bush administration pressured the Centers for Disease Control and Prevention (CDC) to promote abstinence-only programs for preventing teen pregnancy. ● The Bush administration particularly sought to suppress information and to discredit scientific evidence about climate change. ● The administration also sought to distort scientific information by packing scientific advisory committees with ideologues and industry representatives. An advisory committee on childhood lead poisoning prevention was about to recommend that the CDC issue a stricter federal standard for exposure to lead, when the Secretary of Health and Human Services replaced highly qualified scientists on the committee with members who had financial ties to the industry. -Conclusion: ● At its most idealistic, public health is a broad social movement, a campaign to maximize health for everyone in the population through distributing benefits and responsibilities in a more equitable way. ● Public health measures are often controversial because they have an economic impact, and those that must pay the price may not be the ones who will benefit from the new protections. ● Some public health measures are controversial because they arouse moral or religious objections.