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OCRd version of “The Role of The Government In Public Health” by Aubrey Robinson, 1967

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(Paris: 1832). On March 29th, the night of Mi-careme, a masked ball was in progress, the chahut in full swing. Suddenly, the gayest of the harlequins collapsed, cold in the limbs, and, underneath his mask, “violet-blue” in the face. Laughter died out, dancing ceased, and in a short while carriage-loads of people were hurried from the redoute to the Hotel Dieu to die and, to prevent a panic among the patients, were thrust into rude graves in their dominoes. Soon the public halls were filled with dead bodies, sewed in sacks for want of coffins. Long lines of hearses stood en queue outside Pere Lachaise. everybody wore flannel bandages. The rich gathered up their belongings and fled the town. Over 120,000 passports were issued at the Hotel de Ville. A guillotine ambulante was stalking abroad, and its effect upon the excitable Parisians reduplicated the scenes of the Revolution or of the plague at Milan.[1]

If you had been present at such a scene, wouldn’t you want to help? Mightn’t your concern even amount to feelings that you should help? People have traditionally confused such feelings of moral obligation with the idea that a legal obligation must be involved – that people should be forced to help. Out of such reactions to similar episodes have grown the large government operations and controls in the field of public health. Such spectres from the past, of the evils overcome by governmental activity in this area, retain their psychological pull today. They help secure public support for future public health projects and, for the professional public health officer, they justify not simply his occupational existence, but any program in which he is engaged.

Although there is a legitimate basis for anemone to engage in many health projects of a “public” nature, such as health research, contagious disease control and environmental sanitation, the lack of any precise definition of what the government’s role should be in this area makes the present-day public health scene a mixture of legitimate, dubious and wrong activities.

No one has ever differentiated between public health as a potentially useful service and government activities of a public health nature. Most of the activities labeled “public health” form a distinct social service which can be properly performed by private businessmen, not a political or governmental area of responsibility. From the beginnings of civilization, activities such as garbage disposal (which includes sewage systems), supplying water in quantity for towns and cities, rodent control, and the cleaning and maintenance of city streets have been considered proper, almost fundamental areas of government operation and control. The rationale for this opinion was that no individual would undertake a project in which his own benefit was so small a part of the benefit to all – a rationale no longer even plausible in this day of mass markets and mass services.

To these social services has been added a mixture of strictly medical services (hospitals, clinics, and district nurses), some research and experimental work (testing new drugs and pesticides), and many welfare activities (free milk for babies, marriage counseling, and nutritional advice). Today, the public health field in America is becoming one gigantic, confused, loosely constituted institution, composed largely of government activities (with private organizations playing adjunctive and supporting roles), presided over by the Department of Health, Education and Welfare; all of which come indirectly under the influence of the World Health Organization (WHO) of the United Nations, whose medical research is 100% financed by United States tax dollars.

Basically, the question that must be answered is: What is the proper relationship of the government to the public health field? That is the primary concern of this article.

What is public health? There are many “definitions” put forward, almost all of which give one an idea of public health rather than an actual definition.

Almost all definitions in use today agree on two points: a) the group or community is the basic unit (or patient) to be treated, and b) this care or treatment is brought about through “organized community effort.” In this respect, Webster’s Third New International Dictionary is fairly concise: public health is the “Art and Science dealing with the protection and improvement of community health by organized community effort. . . .” Further, in an Introduction to Public Health,[2] it is called “that body of knowledge and those practices that contribute to health in the aggregate.”

However, the definition still considered by public health professionals to be one of the most authoritative is by C.E.A. Winslow in an article entitled “The Untilled Field of Public Health,” which appeared in Modern Medicine in March, 1920: “Public Health is the Science and Art of preventing disease, prolonging life, and promoting health and efficiency; through organized community effort; for the sanitation of the environment, control of communicable infections, education of the individual in personal hygiene, organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and development of the social machinery to insure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birthright of health and longevity.”

It must be noted that the focus of all three definitions is on the group treating a group, which does not in fact happen. It is the individual nurse or public health officer who deals with an individual citizen, to educate him, to treat him, to quarantine him, or to send him to the hospital. If in fact it was the health of the group rather than of the individual that was important, then of course individual rights would not matter. You cut off a leg to save the person’s life without reference to the leg’s “rights” – it has no rights where the health of the whole is concerned. It is this attitude that the devotee of public health legislation would have us take toward the individual citizen when “group health” is at stake.

Also, notice that all three definitions have a lack of definite or precise meaning, which makes it possible to include any sphere of human activity. Hence, the so-called comprehensive approach (euphemism for include everything) in which one treats every aspect of the patient (social, economic, psychological). The result is Big Brother’s dreams come true.

If public health professionals can’t or won’t specify the boundaries of their field, then perhaps an investigation of historical developments may at least indicate in what context we can formulate a more proper definition and area of responsibility.

Most ancient civilizations had no governmental medical services of any kind. Health research was practically nonexistent; contagious diseases were controlled by social ostracism and, in the case of epidemics, by governmentally enforced banishment or isolation. But sanitary services were instituted very early.

The Minoans and Cretan rulers from 5000 to 1800 B.C. had constructed public water systems, and their houses had water closets with flushing systems. The Egyptian Pharoahs (about 1000 B.C.) constructed public drainage systems through slave labor and also developed earth closets, in addition to numerous pharmaceutical preparations. The Jews are considered the first to have developed a formal hygienic code. Their Mosaic law set rules for such activities as disinfection, disposal of refuse, and maternity care.

The Greeks had little government social services of the sort we have been discussing. Their culture emphasized matters of personal cleanliness, exercise, and dietetics rather than environmental sanitation and public water systems. They did have some public baths and aqueducts, which were constructed by wealthy citizens on their own lands.

The Roman Empire developed extraordinary water and sewage systems and paved streets, many of which still exist today. It was the Romans who first formulated the concept of governmentally collected vital statistics, later to become an important adjunct to public health activities. At the height of the Roman Empire, laws existed for the registration of citizens and slaves and for periodic census-taking. The Romans also started government activities in related areas–supervision of weights and measures and of public bars and houses of prostitution, the destruction of unsound goods, and the regulation of building construction.

By the time of the fall of the Roman Empire, public drainage and flushing systems, public water supplies, methods of disinfection and refuse disposal, maternity care, environmental sanitation, regulation of merchant and industrial practices, census-taking, control of rodents, housing laws, and regulation of health hazards and care in industrial establishments had all been thought of in at least some civilization as practices instituted by the government on behalf of “the health of the public.” The Middle Ages added control of epidemics through primitive government-enforced quarantine and isolation measures.

The Middle Ages in general were marked by mysticism and a “mortification of the flesh” that considered the earth and the body evil. This resulted in a pronounced unconcern on the part of the people with personal hygiene and sanitation. It was a time of plague and epidemic. Two of the most feared diseases of these times were leprosy and bubonic plague (“Black Death”) which often reached pandemic proportions, wiping out two-thirds or one-half the population in each settlement or area. It has been said that “nothing before or since so nearly accomplished the extermination of the human race.” “When Pope Clement VI asked for the number of the dead, some said that half of the population of the known world had died. . . . The total mortality from the Black Death is thought to have been over sixty millions. In Avignon where sixty thousand people died, the Pope found it necessary to consecrate the Rhone river in order that bodies might be thrown into it without delay, the churchyard no longer being able to hold them. Europe, particularly during 1348, was devastated.”[3]

Leprosy apparently was a far more acute and disfiguring disease than presently observed in the Western world and, because of the terror to which it gave rise, laws were passed all over the continent regulating the conduct and movement of those afflicted. In many places lepers were declared civilly dead and banished from human communities. They were compelled to wear identifying clothes, and to warn of their presence by means of a horn or bell. . . . [A]s a result, these victims died either from starvation, exposure or lack of treatment and care.” By the sixteenth century, leprosy in Europe was practically nonexistent.[4]

As a result of these plagues, the first formal quarantine measure was instituted in this period. The government of Rogusa in 1377 forced infected or suspected ships or travelers to remain outside of port, free of disease for two months before being allowed to enter the city.[5]

Although the Renaissance was not dramatic for its innovations in public health work as such, the medical discoveries during this period founded modern medicine. All of the discoveries that constitute the basic medical knowledge on which public health practitioners build their professions were the result of the thinking and brilliant innovations of individual men like Leonardo da Vinci (1452-1519), whose sketches and drawings added to his other accomplishments a well-founded reputation as a physiologist; Ambroise Parg (15101590), still considered one of the greatest surgeons of any age; and Andreas Vesalius (1514-1564), probably the greatest anatomist of all time. These basic advances were all made possible because of the general spirit of inquiry and free thought that characterized this period.

The modern public health movement, and the modern concern with social legislation in general, developed in England and America; mainly in England. The precedent set by the Poor Laws in Elizabethan England served to allow extension of these same laws to include health-care services and facilities to mothers, children, the aged and infirm. It was the English who were to give the real impetus and sophistication to the public health movement, not only in this country but in much of the world.

In colonial America, the British government was generally concerned with gross insanitation and with preventing the entrance of exotic diseases. However, vital statistics were early considered essential to sound public health practice. In 1639, an act was passed by the Massachusetts colony ordering the registration of each birth and death and outlining the required administrative responsibilities and procedures.

In England, the first sanitary legislation was passed in 1837. Also, during the nineteenth century, because of the increasing concentration of people in cities, the previously existing poor health habits and insanitary conditions were emphasized. The legislation of this time included bills concerning factory management, child welfare, care of the aged and infirm, mental illness, and education, along with other social reforms. Under the guise of protecting children, the power of the government was systematically increased in such areas as factory regulation and inspection, and the prohibition of health hazards.

It is important to note that much of the government monopolization of public health reforms could not have been accomplished without the demands, urgings, and active support from professionals in every occupational field, from medicine to law to social work. There is a long line of men in the eighteenth and nineteenth centuries who championed various public health laws, projects and programs.

In this country, Lemuel Shattuck (1793-1859) published his now-famous Report of the Massachusetts Sanitary Commission, which included a census of health, housing and sanitation in Boston in 1845. Although this and other such documents were concerned mainly with those health problems that were most obviously the result of human beings living in close proximity, they served to focus public interest and attention on problems of sanitation and preventive medicine.

In England, three men were particularly influential. Jeremy Bentham (1748-1832), student of law and utilitarian philosopher, enlisted the doctrine “the greatest happiness of the greatest number” in support of his contention that public health legislation was needed and that the government must do much more in this area. He has been called the father of modern preventive medicine.[6]

Thomas Southwood Smith (1788-1861), London physician, wrote a treatise on The Use of the Dead to the Living, which led to the passing of the Anatomy Act (permitting the dissection of cadavers in medical schools) in England in 1832.

Sir Edwin Chadwick (1800-1890), lawyer, furthering Bentham’s philosophy through what he called “the sanitary idea,” persuaded the British government to appoint a Sanitary Commission in 1839. This led to the establishment of the General Board of Health in 1848.

All these men contributed significantly to a philosophical climate in which intellectuals demanded that the government provide health and welfare services for all. There can be no true understanding of the public health movement without understanding the philosophy of “social betterment” which has determined the extent and manner of the development of this field. The following quote eloquently summarizes this point of view:

  • As health is an essential factor in human welfare, its maintenance and protection are necessarily of social importance.
  • Under a system where individualism obtains, society tends to take only those public health measures which are beyond the scope of individual action: organization for the prevention and control of epidemics, the provision of public water supplies, sewer systems, milk sanitation, research, hospital facilities, etc.
  • Since, for generations, the social philosophy in the United States was largely one of individualism, quite naturally health problems have been left to the individual, public health work assuming responsibility only for those measures which the citizen, alone, could not institute.
  • Within recent years, society has shown a tendency to assume an increasing responsibility for the individual as an individual, for his education, his employment, his general welfare. (Italics mine)
  • Out of this evolution there has come a tendency to broaden and intensify public health work; and in this expansion government, representing society, appears more and more inclined to regard provision of adequate public health and medical care as society’s responsibility to each individual if he cannot himself procure such service.[7]

It is imperative to remember that public health activities have traditionally been regarded primarily as government responsibilities and only secondarily as a voluntary community activity. It was not, in the beginning, government that encroached upon private agencies taking public health responsibility; it was assumed to be a field for government prerogative. The government has mixed various unrelated health-control measures with voluntary community health activities into the field we now recognize as public health.

In the late nineteenth- and early twentieth-century America, many private agencies did develop. Most hospitals and clinics have been built with private funds. The American Red Cross, although chartered by Congress and working in cooperation with government agencies, is supported by voluntary contributions and staffed by volunteer workers. Margaret Sanger’s birth control movement and the National Tuberculosis Association are good examples of private agencies who have provided medical and health-educational services to millions.

But in the 1930’s, the American government’s public health measures began to expand under the New Deal administration. And then, but a sort of natural impetus peculiar to governments, the administration extended its control and influence through administrative fiat and legislation, under pressure from special interest groups, both governmental and private. The recent trend has been toward the continued incorporation of various social welfare schemes into one giant federal organization: the Department of Health, Education and Welfare (1953). This department (now of cabinet status) is so large and so complex that a library of books would be needed for a complete study of its bureaus and divisions potentially involved in one health area, such as maternal and child care. Once this consolidation of agencies was well started, the government then proceeded to utilize social security funds (as it is now doing) for such programs as mental health, heart disease, and dental health.

In his paper, The Impact of the Great Society on Public Health Practice,[8] Edward S. Rogers, M.D., Professor of Public Health and Medical Administration at the University of California School of Public Health at Berkeley, quotes Secretary John Gardner, of the Department of Health, Education and Welfare: “The whole movement of events in recent years has been not toward the separation but toward the interweaving of the Department’s various objectives. With the enactment of Medicare legislation, health and social security are inextricably linked. It is impossible to conceive of a modern welfare program without a strong educational component. Programs concerned with juvenile delinquency, mental retardation, and aging cut across the old categories. An adequate attack on poverty defies bureaucratic boundary lines.”

For a graphic illustration of the relationships that exist between private medicine and the forces for social medicine, the following quote from the same article is unequaled. Professor Rogers states: “Between the time of the passage of the Medicare Act . . . the subsequent passage of the heart disease, cancer and stroke legislation (DeBakey Program) in the same year, a total change in the relations between the Federal government and the AMA occurred. . . . The AMA suddenly changed its course in favor of working constructively in support of the bill. . . . The government welcomed this cooperative approach – and the lion and the lamb lay down together. This was a significant event because these two great forces for better health services had too long been at odds with each other. In the philosophy of creative federalism, the government needed the AMA. In the philosophy of pragmatism, the AMA recognized the growing pressure of a public consensus.” (Italics mine.) There are two questions left to ask: Which one is the lion and which is the lamb? and, what happens to the lamb?

We now have a general idea of the gradual development of the field presently called public health into the government’s own preserve.

Intellectually, this was accomplished through lack of any context for defining proper governmental public health concerns; the failure to differentiate between public health as a field of private endeavor and government activities of a public health nature; and the philosophy of pragmatism which evades principles and focuses only on methods and concretes.

Politically, this was accomplished through the doctrine of “social betterment” and the concept of the “right to housing, jobs, health and other necessities of life”; and the large, tacit, assumed government responsibility for the general welfare, both of which bastardize and mock the legitimate concepts of rights and individualism.

Psychologically, it resulted in part from a distortion of the valid respect many people hold for medicine in general. Through handling and treating health problems, the health practitioner acquires familiarity and efficacy in dealing with situations of fundamental necessity to health and life: in a very special way he “knows what makes life tick.” This inspires respect and a sense of awe for many people which, if extended, can indiscriminately envelop anything which is said to be medical. The result is a kind of charisma attached to the medical spokesman. This charisma sometimes prevents people from critically evaluating any public health project: if it will help the doctor it must be good. It is the government that is today cashing in on this charisma.

What is wrong with government public health work? Apart from being an expense of millions of dollars to the unwitting taxpayers, apart from the inefficiencies of sprawling agencies rife with red tape and duplicate services, public agencies are forcing private competing agencies out of business, and public health laws are used to extend the tyranny of the bureaucrat over the citizen.

The question is: How does one apply the standard of protection of individual rights to delimit government operations, responsibilities and authority in the field of public health?

There are areas of responsibility now included in public health work that are validly governmental in nature. These must be explicitly defined and recategorized under a heading such as Health Law. This is so because the only justification for government involvement in any area of the citizen’s life is the protection of rights (by which I mean life, liberty and property). This field of health law would be concerned exclusively with infringements of rights of a health nature. It would be applied through standard courts, never through administrative agencies, and would employ the legal weapons of search warrants, injunctions, contempt-of-court proceedings, arrest and trial–never regulation and regulatory inspection. The foregoing description obviously excludes the operation or control of any public health facility or organization by the government whose purpose is not exclusively the protection of rights.

Valid areas of government assumption of public health responsibility would therefore be areas in which the use of force or the threat of force is required in order to protect the legitimate rights of other citizens. Such areas would be, for example, the arrest and prosecution of persons specifically accused of polluting the air or water supply; the enforcement of laws against maintaining known health hazards to neighbors on one’s property; the enforcement of laws against selling polluted or disease-carrying products; provision for institutions for the criminally insane; and some quarantine laws. Those areas (such as air pollution) which have been handled mainly in a regulatory manner to date would present special problems because of the scarcity of legal precedents. Although we don’t know all the answers to these problems, the standard for drafting legislation would always be that the right to property does not give one the right to harm others. Such areas as emergency provisions for life-saving measures on the part of the police would not be affected, as these are not properly considered public health measures but protection against possible death from crime or criminal neglect. This does not basically change the nature of government activities as here stated.

Most of the present public health activities of the government would be considered illegitimate. The medical services now provided by public agencies would be provided by private agencies which would have no power to force treatment on the individual. Sewage disposal, the provision of water systems, and similar social services would be performed by privately owned companies. The control of health research, hospitals and clinics would, of course, be in private hands.

In this country medicine has been traditionally a free-enterprise operation, not a state service. Why did the medical profession acquiesce in the incorporation into the government colossus of so many areas that were theirs? In large part because present public health services are not thought of as being based on the use of force. Taxation is rarely recognized as a use of force, neither is ruinous government competition. In public health, more than in most areas of government activity, methods of operation are through persuasion, research studies, dissemination of health literature, grants-in-aid and consultation and evaluation services.

America is a curiosity in this respect; she specializes in the indirect rather than the direct use of force. Because she still has some respect for individual rights, here infringement of these rights necessarily takes a different form from that in countries in which there is little respect for this moral principle–which is most of the world. America is kinder, more considerate, less brutal; and, as a consequence, less obvious. How does the average nonpolitical professional refuse money for research projects, medical school construction and various other endeavors? Given his situation, he doesn’t.

But the government interference that this average professional would recognize and reject in private practice can strangle the field he loves. It is time that he started to understand it.

-Aubrey Thornton Robinson

[1] Garrison, F.H., M.D., History of Medicine, 4th ed., reprinted, Philadelphia and London; W. B. Saunders Co., 1966, p. 775.

[2] Mustard, H. S., M.D., LL.D., Stebbins, E. L., M.D., Introduction to Public Health, 4th ed., New York: The Macmillan Co., 1962, p. 16.

[3] Hanlon, John J., Principles of Public Health Administration, 2nd ed., St. Louis: C. V. Mosby Co., 1955, pp. 29-32.

[4] Op. cit., pp. 29, 30.

[5] Op. cit., p. 31.

[6] Guthrie, Douglas, M.D., A History of Medicine, Philadelphia: J. B. Lippincott Co., 1946, p. 387.

[7] Mustard, op. cit., pp. 3-4.

[8] Paper given at 1966 American Nurses Association Convention. @ 1966, American Nurses Association.

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