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from The Chronicle of Higher Education The Chronicle Review
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From the issue dated November 9, 2007
What Ails Public Health?
By PHILIP ALCABES
Public health, once the gem of American social programs, has turned to
dross. During the 20th century, the public-health sector wiped smallpox
and polio off the U.S. map; virtually eliminated rickets, rubella, and goiter; stopped epidemic typhoid and yellow fever; and brought tuberculosis — once the leading cause of death in U.S. cities — under control. It sought, with considerable success, to reform social and economic structures so the poor would have the same chance at decent health as the wealthy.
But public health seems to be a phenomenon of the past, like the Great Society or the New Deal. Not that we don't talk about it, or teach it: There are 38 accredited public-health schools and 67 other institutions offering accredited master's programs in public health in the United States, and more are being developed. If we in the academy are as serious about public health as the profusion of professional training programs signals, then we can begin restoring the field by changing how we teach it.
We have to revise our teaching radically because evidently we are failing. One testament to our failure is the activity of American health officials, the products of public-health training programs. In the past six years, Americans have seen officials redirect tax-levy funds to pay for ludicrous "biopreparedness" exercises in anticipation of wholly fabricated epidemic dangers, concocted by an administration unable to admit its mistakes after September 11. We have heard officials endorse useless "virginity pledges" for teenagers. We have seen them invoke federal quarantine law — claiming there was a hazard to the public — to arrest one man who had flown on an airplane while carrying noninfectious tuberculosis. We have listened to them tell us that our improper diet is the second leading cause of death in America. A couple of years ago, the health commissioner of New York City ignited a moral panic by issuing an official health alert over a single case of AIDS, pontificating about condom "complacency." Most recently, health officials have swept transfats out of restaurants. (If this has not happened in your town yet, it will — because no health official can afford to miss the bandwagon of banning demon foods, even, or especially, ones for which there is little sound evidence of serious harm.)
But in the past six years, no health official has argued forcefully for social changes that would genuinely improve the public's health on a significant scale. While we hear plenty about how personal "lifestyle" changes can make us healthier, health officials are not pushing for social fixes that would have even more powerful effects by limiting inequalities in wealth or their health-impairing correlates. They don't demand reforms of the sort that would make us more like those developed countries (Denmark, France, etc.) where infant-mortality rates are more than 20 percent lower than ours and where life expectancy is longer — changes like more affordable housing, a guaranteed minimum income, a higher minimum wage, restoration of workplace-safety oversights emasculated by big-business-friendly government, or better and cheaper public transportation systems.Broad reforms in the public sphere still happen, and sometimes to the benefit of Americans' health, but health officials have not created them. Housing-policy experts link the supply of affordable housing to healthiness of neighborhoods; health officials, with a few vocal exceptions, are largely silent on the matter. Workplace safety is left to the Occupational Safety and Health Administration and the National Institute for Occupational Safety and Health, the federal agencies explicitly dealing with occupational health; health commissioners have merely moved to ban smoking in bars. The corporate world, no longer able to afford the cost of employee health insurance, will probably push through universal health insurance in some form soon; but too many public-health officials have lost interest in reforming health-care finance.
The decrepitude of contemporary health policy is especially lamentable because the old model of public health worked so well. Traditional public health — health improvement through social reform — dramatically altered the way Americans live and die. In the course of the 20th century, educating women and opening jobs to female workers were central, and so was offering information on family planning: Together, those factors reduced family size, which contributed more strongly to longer American life spans than any other factor. Enhancing nutrition through food inspection and by fortifying or supplementing common foodstuffs undercut the nutritional consequences of poverty. Creating public pure-water and sewage systems made cholera, the scourge of the 19th-century poor, an anachronism. Providing adequate housing, social-welfare benefits, and public baths and sanitary facilities relieved the squalor of the working class's living conditions, limiting the circulation of typhoid and other contagious diseases. And broad-based immunization programs all but eliminated the great threats to children's health, like polio, diphtheria, and measles. Public health might not have put money in the pockets of the indigent, but it restructured American society in order to ease bodily suffering.
That model has gone belly up. Public-health officials forsake the restructuring of society, and public-health professionals outside of government, including academics, often back those officials in their grandstanding and empty gestures.
When officials publicize one or another case of HIV transmitted by
someone who should have known better — the New York City case in 2005, an upstate New York case in 1997 that became a media carnival, another in South Dakota in 2002 — some of my colleagues have contributed to the ensuing moral panic. "Sometimes you have to scare people to get them to do the right thing," they tell me. Many did the same last May when federal agents manufactured a health crisis where none existed by calling a news conference to alert the public about the man with tuberculosis who had flown on a commercial airliner. Even though airplane-cabin air is not conducive to the spread of TB bacteria, the man was not infectious, and officials knew that tests of the TB strain in question were incomplete, still some academics in the field ratified the official manipulation by calling the hapless man "grossly irresponsible" and turning a public-health nonevent into a security breach.Public-health professionals also enabled the panic over West Nile virus, backing the spraying of insecticides onto parks, streets, waterways, and sometimes passers-by, when there was no cause for alarm. (West Nile does cause serious illness and death — but control of mosquito larvae in standing water is more important than killing the ones that are flying; window screens and long sleeves are effective mosquito deterrents; and the low rate of West Nile illness even in an outbreak doesn't justify the risk of putting toxic pesticides in the water supply and onto people.) And many of my colleagues support the bans on transfats, so friendly to corporate food producers like Frito-Lay and McDonald's — who can now entice people to eat their products with claims that they are "transfat free" — but of no use to the public. Others subscribe to the moral panic over crystal meth, hysterically associating it with the spread of HIV, despite the lack of evidence.
In place of the old model of social reform, today's health policy revolves around magical thinking. One part of that is a fantasy that Americans are susceptible to unprecedented disasters because of global travel and trade. There are epidemics, sure. But the U.S. Centers for Disease Control and Prevention remains very good at detecting and directing the control of outbreaks when they do occur — the severe acute respiratory syndrome (SARS) episode of 2003 offered abundant evidence of that capacity — and the structure of 21st-century American society does not enable contagion of the sort that caused catastrophic mortality in 1918 from influenza and in 1849 from cholera. (We have smaller families, are less often clustered in unavoidable close contact, and have municipal water and sewage systems.) Even HIV, the main pandemic virus of our era, spread relatively slowly in the United States, after its initial inflammations of the late 1970s and early 80s.
But facts are only scenery when the main plot is driven by an idée fixe about global threat. The international spread of SARS in 2003 was taken as evidence of that danger, despite our self-evident capacity to control it. So was the importation into the United States of a cow infected with mad-cow disease, discovered in 2003, although we're still not sure that the mad-cow agent is transmissible to humans at all. So was the spread of avian flu among bird flocks, even though the virus in question cannot be transmitted from person to person and therefore poses negligible epidemic hazard to human populations. And so was the Airplane Man, the young man with TB who became an object lesson in our supposed vulnerability. Bowing to the fantasy of global threat, the CDC leads a project called "Protecting the Nation's Health in an
Era of Globalization." Accordingly, officials in diverse jurisdictions mount elaborate charades of "emergency preparedness," claiming they aim to protect us from "bioterrorism" or "emerging infections." They — and we, perforce — worry.The other part of the magical thinking concerns personal behavior. Officials badger us to quit smoking, exercise more, eat more fruits and vegetables, avoid drugs, use condoms, reduce our stress. We are all simpletons, it seems, and need to be reminded to act in our own best interests. That we might choose to drink too much, eat fast food because we like it, skip the latex because the sex feels better without it — that, as Susan Sontag remarked, "appetites are supposed to be immoderate" — is not open for consideration. Apparently it doesn't matter that, according to available evidence, most people who eat more fruits and vegetables to avoid dying of cancer would not have died of cancer anyway, or that the most likely cause of death for people who exercise more (heart disease or stroke) is the same as that for those who don't.
That many people are too poor to afford the time or the expense of eating whole foods, exercising regularly, or reducing their stress is not part of the magical equation, either. Indeed, the matter of who can afford healthful behaviormight be exactly why the behavior-change crusade is so compelling: If you can afford to shop at a farmers' market, go to the gym, take a vacation, or live in a downtown apartment so you can walk to your office, then you are manifestly not a member of the unwholesome class. Your healthy behavior proves that you are a Worthy in the modern American moral register of health.
Not that behavior is irrelevant: Using condoms, quitting smoking, and eating healthfully do matter. The point is that while changing your behavior can make an appreciable difference to your health, it doesn't necessarily make any difference to society's health — not the difference that a guaranteed minimum income would, or child care, or health insurance. This is the magical thinking of behavior change. Our public-health authorities try to convince us that everything
will be better for everyone if only each one of us would do the right thing. It's a little like believing in angels.Magical thinking is especially odd in our time because this is purportedly the era of evidence-based policy, at least in health. Indeed, our public-health-education programs have become good at teaching how to amass and interpret evidence. But apparently we do not teach how to distinguish evidence generated by good science from evidence produced by bad science. For instance, only weak evidence exists that eliminating transfats alone from the diet will reduce heart-disease risk, and no evidence that it would have any impact for most people (transfat consumption is pretty low in America today). There is no evidence linking crystal meth to actual acquisition of HIV, beyond the known pathways for contracting the virus — although plenty of studies show an association between crystal-meth use and behaviors that people think of as bad (sex with multiple or anonymous partners). The evidence on secondhand tobacco smoke points to a substantial effect for children of smokers but a milder one for adults, and essentially onlyfor prolonged exposure in the home. (If you really wanted to reduce disease risk, you would have to ban smoking at home, not in the workplace or restaurants, and then lock up the miscreants, leaving their children to be raised by smoke free strangers while their parents were incarcerated.)
It isn't so much that health officials ignore the evidence; it just seems tangential at best — important only if it relates to how people behave and not very interesting in its details.
In this way, public health today moves closer and closer to religion. Like Western religions, it is deeply interested in behavior as a way of distinguishing the elect from the masses. And it is less
interested in empirical examinations of truth. The authority of simple, received wisdom — fats are bad, cigarettes are worse (and tobacco companies are demonic), exercise makes you whole — trumps the fine print of the inevitably complicated story that science uncovers. No wonder that, when I asked how we in the public-health profession will explain our failure to say anything about AIDS prevention other than "use condoms" (advice, I pointed out, that is ignored by most adults much of the time, anyway), a senior colleague admonished me to never say that in public. It is easyto show that promoting the use of condoms has essentially no population-level impact on the AIDS epidemic in this country, given the relatively low prevalence of HIV in most U.S. populations and the very low proportion of people who use condoms consistently (other than teenagers, by the way; American adolescents are very good at being careful sexually). But that would be a calculation based on evidence, and therefore beside the point. What I was saying was blasphemy.Can we educate the next generation of public-health professionals to dispel magical thinking like that? Can we teach them to topple feckless officialdom, forswear the sops to corporate producers on the one hand and ideological dogma on the other, and create real reform? Can we restore the twin pillars of rationalism and social justice — and somehow overcome the pernicious dictating of behavioral correctitude?
If we are to do that, we have to change what we teach, and how. Reform that gives the poor the same chance at decent health as the rich has to return to the center of American discourse. It can't be sidelined as a charming anachronism of the Great Society. But that means that we will have to eschew the old rites of the New Left: the religiosity of ideology; the hand-wringing over race; the belief in a magical vinculum joining identity to oppression, oppression to vulnerability, and vulnerability to victimhood.
Not that racism is gone, alas. The legacy of the race-saturated opportunism that helped build
the American medical establishment — a history sparklingly elucidated in Harriet A. Washington's Medical Apartheid — remains to be overcome by the medical profession and continues to affect Americans' health. But a greater threat comes from what the sociologist Troy Duster calls the reinscription of the biology of race: the use of medicine — and, I will add, epidemiology — to grant biological cred-ibility to a hierarchy of social desirability.We all agree that race doesn't exist biologically: There is no DNA signal that reproducibly encodes blackness or whiteness. But talk of risk makes it seem that it does. To identify African American "ethnicity" as a correlate of susceptibility to prostate cancer, as a recent report in Nature Genetics does, or to license a heart-failure medication (BiDil) for African-Americans only, as the Food and Drug Administration has done, is to create a biologic race where none exists. To claim, as a recent article in the American Journal of Epidemiology does, that race is associated with higher levels of "risk behavior" (in this case, smoking cigarettes and marijuana and drinking alcohol) is not only to misappropriate the idea of risk in order to condemn disapproved activities; it also reifies race by associating it with presumptively noxious, morally reproved behaviors.
In the new public health, where behavior is scrutinized and social vulnerability replaced with victimhood, other groups become races and take their place in the hierarchy of the Worthy: Hispanics (diabetes), gays (AIDS, syphilis), and now fat people (heart disease) are inked with the mark of disease risk. Social reform, that old thing, won't help; race is imprinted in the genes.
If we go on teaching our students to focus public health on so-called racial/ethnic/sexual preference disparities, we will train yet another generation of officials to claim that your health problems stem from your membership in an identity group. The racially upright can expect to be fully healthy, but the second-rate cannot. Sell them different products, aim different programs at them, but do not, for a moment, pretend that their problems can be fixed by more financial support, broader access, or fairer distribution of services. Health officials can continue to ignore the shrinking availability of health insurance, the paucity of decent housing for the poor, or the multiple insults to health that are the constant companions of dwellers in some poor, urban neighborhoods. They will go on blaming health problems on attitudes,which are beyond the reach of reform, and get away with wagging their fingers at bad behavior.
Finally, we have to develop curricula that face the vexatious positioning of health as a moral issue. We have to teach the new generation of public-health workers that, outside of Leviticus, there is no moral basis for telling people how they must spend their time. Nor is there moral probity to being healthy. The specter of ill health should not be a stick with which to compel prescribed behavior.
Yet health today also bridges the once-appealing dichotomy of Right and Good, the distinction between the just guarantee of all individuals' civil rights and the just distribution of services that might make peoples' lives better. The sum of insults to health seems to impair a fundamental freedom. So talking about health in our time pitches us into new moral ground. We have to teach the next generation of professionals to take on more-complicated moral and social questions.
We in academe can educate a new generation to replace today's advocates of magical thinking. It will take some open-mindedness, plus the will to resist the inertial tug of old dogma. But restoring sound public health to the American social dialogue is a worthy goal. To quote from Tony Kushner's Angels in America: "More life. The Great Work begins."
Philip Alcabes is an associate professor of urban public heath at the Hunter College School of Health Sciences of the City University of New York. He is writing a book on the history of thought about epidemic disease.
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