Dear Public Health: the public despises you, so you are probably doing it wrong

by Carl V Phillips

A collection of disjointed, though related, thoughts I have had for days, months, and years have coalesced together in a very interesting way. The thesis here is a theory I have evolved based on experience and focused thought over a couple of decades, not some flight-of-fancy. Still, I grant that this story is necessarily simplified and certainly there is room for debate. Also, as will quickly become apparent, this is not a typical post for this blog, but it is quite relevant.

The title of this post is something I paraphrase periodically in a tweet. But that phrasing is something I would have rejected a decade-and-a-half ago, when I first started working in THR. At that time, I repeatedly objected to the opponents of harm reduction being referred to as public health, which is of course the diametric opposite of what they were and are, assuming we think that public health is about improving people’s health. 

At the time, there was no serious grassroots support for THR, so proponents of trying to provide tobacco users with information and products consisted of elements of the tobacco industry, a couple of pundits, and a few independent scientists. (And I do mean a few. There were not enough of us to have a conference, only about enough for a carpool.) So that is who talked about it, and so I had ample opportunity to be offended when the industry people referred to the harm reduction opponents, as they always did, as public health. As in “this could prolong millions of lives, but public health is going to object to it.” I objected that I was part of public health (it said so on my business cards, after all) but those people were just a special-interest group that was misappropriating the good name of public health.

For those who are new to this world and have never learned its history, anti-THR was alive and well from the 1990s, when the first concerted pro-THR discussion began, thanks largely to Brad Rodu and a few people from Sweden. In many ways, attacks on smokeless tobacco then (and still, for that matter) were worse than the current attacks on e-cigarettes. At least anti-ecig crusaders sometimes attempt to hedge with claims about unknowns, renormalization, gateway, and the like, while the anti-ST playbook was (and still is) simply out-and-out lying about health risks in the face of overwhelming evidence to the contrary. On the other hand, anti-THR at the time was pretty much limited to a small number of anti-tobacco extremists, though they were quite effective because they had already captured the U.S. government and other effective megaphones, and the falsehood that all tobacco is highly harmful was pervasive. Still, the typical public health professional was as much an ignorant victim of the monolithic disinformation campaign as the public, in contrast with public health’s widespread active support for anti-THR today, in an information-dense world where they have no excuse for ignorance.

I continued to protest crediting anti-THR activists as being part of public health for a long time, but with decreasing frequency and enthusiasm. As the discussion about THR grew, the anti-THR special interest movement grew and continued to claim that they were part of public health. So at some point the real public health people could no longer be credited with merely not knowing about this misuse of their increasingly-not-so-good name. In 2000, a state public health official, leader of a public health NGO, or even professor of public health whose focus lay elsewhere could be forgiven for not even knowing about THR, let alone that it was being attacked in their name. By 2010 that was clearly no longer the case.

In the 1980s the spiritual forebears of the grassroots THR movement taught us “silence=death”. Perhaps that is a bit strong for the present discussion, but it is certainly the case that silence=complicity. It was in a conversation with Chris Snowdon, at about the time that I was deciding I could not stand to have the phrase public health on my card anymore, that I finally conceded, “Yeah, screw this trying to defend that phrase against those who are abusing it this way; let the card-carrying public health people defend it if they want, and if they do not, let them share the disdain and disrespect that those abusers are earning for the whole field.” Of course there are and always were people doing good, valuable, real public health, and it is unfortunate that they are tarred with that brush. But, hey, that is what happens when you do not police your own. So now I do not hesitate to use the phrase in the derogatory manner that has become common.

An extremist political faction grew out of real public health work on tobacco that occurred decades ago, becoming the tobacco control special interest group. That has now metastasized such that a large portion of what is called “public health” is really about the nanny state. So the shoe fits. Of course, readers of this blog will know that I try to acknowledge the existence of real public health, despite the fact that its ugly progeny are now the tail wagging the dog, by using the scare-quoted “public health” to refer to the nanny-state political movement. But, as I said, I no longer to try very hard to draw the increasingly thin distinction. It becomes harder to condone the failure of self-policing as the nanny state becomes more the bully state, exhibiting the characteristics described below, and still there is no hint of self-policing.

But perhaps most important, it is now apparent to me that those progeny are not hybrid offspring that defy the core spirit of public health as an intellectual movement and institution. Rather, public health has bred true.

That is not, however, due to the reason you might think. Those who know the history of public health will realize that the germ of nanny-state behavior has always been there. Public health started as a strange combination of fad-diet and temperance nuts along with practicing health professionals who were enlightened enough to be concerned about eliminating disease rather than just treating it. It pulled in established good works such as food facility inspection, occupational health, and vaccine campaigns, and had a legitimate scientific and institutional identity by the mid-20th century. Through several ensuing decades it was mostly legitimate, but the temperance nuts were still there.

My first encounter with that undercurrent was when I was in grad school, in a different field, writing a paper on the benefits of moderate alcohol consumption. (Please don’t go look it up. It was naive. I was young and had not figured out that the economist penchant for carpetbagging in fields where they lacked expertise — see, e.g., almost every popular book written by an economist — was a bad thing.) I came across a lot of “public health” papers that insisted that the observed health benefits of alcohol consumption were not real, grasping at straws to deny overwhelming evidence. I was genuinely baffled at how people could be making such errors. It would be years later before I realized that they were simply lying because that is what you do in “public health” when the facts do not support your preferences about how people should behave.

But it turns out that it was not those temperance nuts that created the foundation that doomed public health to become what it is today. They found fertile ground for their crusades there, of course. But it was actually the narrow-minded health professionals who doomed it.

Back to the present, we have a compelling illustration of the descent of “public health” and its abandoning the pretense of caring about people: the John Ashton scandal. For those who do not know, he is the head of a British organization that fancies itself The Faculty of Public Health and claims to represent public health (so take that as your starting point, even though it is really more a political think-tank like any other). He recently went off like a drunken adolescent on Twitter, personally attacking people who questioned or expressed disagreement with his extremist anti-ecig positions. He then pushed a fabricated story into the press in which he claimed that he was merely retaliating for nasty things that were said about him, though it turns out those were all said after his tirade. His attacks were of a tone that might even cost an NFL player his job, let alone a professional who is supposedly working in the public interest. Surprisingly, the FPH suspended Ashton from his duties and claimed to be conducting an investigation. Not so surprisingly, a week later, they proudly announced he was returning to his duties. The FPH did not apologize for the lashing out itself or the attitude — merely for the profane language used. Ashton stated that he regretted what he had done — no kidding! — but he too failed to apologize.

(For more on the story in case you are not familiar, follow back the links from Dick Puddlecote and Clive Bates, and see in particular Lorien Jollye who led the charge about it.)

The real scandal here is not that one self-important think-tank was unwilling to get rid of its president over grossly unprofessional behavior (though that is a scandal), but that “public health” rallied around him. Here is a supposed adult who publicly said “fuck you” to members of the public who he is supposed to care about (he did not use that exact phrase as far as I know, but actually did use other words that I would not type into this blog). The people he attacked were disagreeing with him almost entirely in a polite and professional way. And yet I have not seen one single statement along the lines of “this is a real shame because I respected Aston for years, but for the credibility of public health, he has got to go.” Not one sign of remorse from the institutions of public health. Instead, I have seen a number of public health academics and other supposedly respectable professionals actively speaking up in his defense. These communications represented (and in some cases, basically explicitly stated) the attitude that “public health” does not owe the public any consideration at all.

Put another way, public health stopped being about health when they started denying the health benefits of THR or alcohol. Then they stopped being about the public when the decided that it was not a problem that the public hates them for what they are doing.

Taking another trip back in this fugue, I recall a conversation with a fellow economics-trained assistant professor of public health. I forget the specific trigger for our observation, but it came after a meeting of faculty, when we both realized that we were surrounded by idiots. The issue was public-health-based policy recommendations and their absurd implicit objective function. Our observation was that in economics we often lean on the convenient myth that people’s goal is to maximize their lifecycle welfare, and that social policies should be based on that. It is easy to demonstrate that this is an oversimplification of behavior, and to argue from an ethical standpoint that there should be some departures from this in policy. But at least our simplified fiction is basically sound, both practically and ethically: Trying to maximize their welfare is roughly what people do, and there is an obviously defensible case to be made that trying to assist with such maximization is an important ethical goal — if not the ethical goal — of public policy.

We observed how sharply this contrasted with the implicit objective function in almost every public health policy discussion, which is basically “maximize longevity at any expense, and everything else be damned.” The economists who study medical care at least interject into this the caveat that some financial expenditures are too much to pay for the tiny bit of extra longevity they provide. But to the public health people, all other costs and benefits are trumped by the one objective. Economists’ objective function, we agreed, was not quite right, but at least it was generally defensible. The public health view, on the other hand, was utterly absurd. No one wants to live their life according to such an objective. Not even close. And therefore there is no possible way to justify it as an ethical goal for public policy.

This absurdity is the seed of destruction that was built into public health, uncritically accepted even by those who are not part of the “public health” political faction because they are so immersed in it that they do not even realize they are making a very strong (and indefensible) assumption. It is effectively built into the language of public health discourse and thus it is almost like the Sapir-Whorf hypothesis or its literary extension as Newspeak: the available language makes it impossible to think contrary thoughts.

This pseudo-ethic was not created by temperance nuts, but by health researchers and especially medics, who in their arrogance and narrowness decided they could recommend decisions for society based entirely on technical analyses, just like they do in the clinic. They morphed clinical science and decision-making into a social science without ever acknowledging they were now applying a model that is right for fixing biological machines to actual humanity. They adopted the word public, but it did not mean what we normally think the word to mean. It just means “the people as a whole”; it does not mean that people are anything other than machines that need to be fixed. In their arrogance, they did not think they needed to consider the views of economists or other social scientists who are immersed in the study of humans as something other than biological machines, nor that they should not create an ethical system without reference to the wisdom of people who study ethics. (It is telling that the field of “medical ethics” is basically a subfield of law; it is about compliance with rules, and bears little resemblance to discussions of ethics.) Of course, neither the denial of other considerations nor the process by which their pseudo-ethic developed was a conscious decision by any individual or group — it just happened that way because that is how those people roll.

The temperance nuts were present at the creation and there all along, and they may have found a better home for their social engineering goals than they could have ever hoped for, but it was not their doing. It was the medical professionals who doomed public health to become the comfortable home for the likes of John Aston and the others who think his actions were perfectly fine.

Now, I do not want to overstate that point. The goal of preserving bodies without reference to the people in them obviously does not explain why public health objects to the fact that alcohol is good for you and opposes THR. But because the pseudo-ethic of maximizing longevity at the expense of anything else is inherently indefensible, it offers no defense against attaching amendments that are even worse excuses for ethics. Thus the temperance nuts took their chance, and amended the pseudo-ethic into maximizing longevity at the expense of all else, but with “proper” behavior trumping even longevity. While there is a bit of pushback against that amendment from some quarters of public health, it is generally pretty feeble. Thus, not only is drinking to excess a violation of the one goal of public health, but drinking at the level that is healthy violates the amended version. Not only is choosing to smoke a violation of the one goal, but choosing to use a low-risk alternative violates the amendment.

To the extent that people’s preferences and choices run contrary to objectives embodied in this pseudo-ethic, they are part of the problem. It is not a big step, then, from “people’s preferences and choices are part of the problem” to “people are part of the problem.” Each of us is, to ourselves, largely defined as our preferences, desires, behaviors, and experiences. But to “public health” we are just a steward of a body, and we are not doing the right things with those bodies. (The resemblance to those who think we are just a steward of a soul and are not doing the right thing with that soul is not coincidental.)

So, “public health” does not mind that the public hates them. They do not even embarrass when they demonstrate that they hate the public. They do hate the public (as most of us would define it) because we are hurting the public (as they define it). That is, they hate all these actors whose volition often hurts or defiles the bodies that they are the self-appointed defenders of. To us the public is those actors and that volition. To them, it is just the sacks of meat that have the misfortune of being controlled by those pesky actors.

Circling back, Clive Bates, in the above-linked post, pointed out that it was inappropriate for public health professionals to whine about people saying mean things to and about them on social media, and even more inappropriate when they lash out. He sagely observed that this is an asymmetric relationship and then (oh so politely, and definitely not in so many words) ridicules them for sounding like children protesting, “He hit me first! I was just hitting back.” The public does not owe the public health grandees (his phrase) respect or the civility that is earned through respect.

I would add that when those in public health habitually lie and casually act to upend others’ lives in pursuit of their personal vision of proper living, they earn the same disrespect owed to a marauding horde. Despite that, members of the public actually show a lot more civility than the accusations suggest, and the whining professionals rewrite it in their heads as disrespectful for the reasons observed in the final passage in this fugue.

People have every right and reason to say terrible things about politicians and oligarchs whose actions affect their lives, while it is gross and pathetic for the oligarchs to respond in kind. But Clive argues that the asymmetry goes beyond that generic version in this case: Public health people complaining about the public “is like sailors complaining about the weather…. They are the subject of your profession – get used to them”.

Ah, but there I think is the problem. It certainly should be the case that the public, as we define ourselves as people, is the subject of their profession. But it is not. The weather analogy is perhaps more apt than originally intended. Sailors do complain about the weather (often using much the same profane language used by public health professionals on Twitter) even as they get used to it and try to understand it. The weather, like those pesky preferences and volitions, is a critical variable that sometimes cooperates with the goal — which is not about the weather any more than the goal of “public health” is about making people happy — but is sometimes a threat to the goal. The voyage and the bodies are the goals of the respective professions, and the weather and the uncooperative human actors often work against those goals. Though in fairness to the sailors, I suspect they are professional enough to not feel a personalized hatred for the weather when it is not cooperating with their goals.

I am reminded of my undergraduate days when I made a study of, among other things, ecology (the biological science, not the associated political movements). In my last term, on a whim, I signed up for a graduate “insect ecology” class and was quickly struck by the different underlying policy undertone. All these classes focused on assessing the material reality, which is amoral and without goals. But when the conversation did stray into preferences and actions, the underlying motif in most ecology classes was about helping preserve the organisms and systems we were studying. But in the world of insects, it was mostly about how we could best kill them. Indeed, the dominant purpose of entomology is to figure out what insects do and why in order to better stop them from doing it.

I have been struck many times since then by how “public health” studies of people’s preferences and behavior generally serve basically this same purpose. Sailors study the weather so they can pursue their goal in spite of the weather’s “attempts” to divert them. Practical entomologists try to figure out how to stop bugs from taking some actions the bugs “want” to take. Tobacco control and others in public health study people’s preferences and volition only for the purpose of figuring out how to stop people from doing what they want to do. The difference among these statements is, of course, the lack of scare quotes around the want in the latter one. People, unlike the weather or bugs, really do want what they are pursuing. But “public health” often sees their goal as being the same as that of exterminators, to prevent autonomous actors from achieving their goals.

Coming forward again to another moment from this week, there was apparently another one of those seemingly monthly conferences on the “endgame” (which, incidentally, is a laughable misnomer), the tobacco control fantasy of eliminating all tobacco product use. Ruth Malone, channeling Stanton Glantz (as she often does) mused on Twitter about whether e-cigarettes should be part of the endgame strategy too. The predictable responses ensued, but I interjected with the observation that the real problem here is goes deeper than that question. The real problem is that people like her think they have some kind of popular mandate or ethical basis for trying to engineer their “endgame”. They do not. They are trying to force people who want to take a particular action, in spite of its costs which they are fully aware of, to stop doing it even though it imposes basically no substantive costs on anyone else (and, indeed, provides net benefits for the rest of society). There is no defensible or accepted ethical system that offers justification for this. None.

Sometimes I observe that the nanny state supporters must believe in a feudalistic or fascist ethic, in which all of someone’s possible labor belongs to his lord or his state, and thus any behavior by the individual that reduces his available labor is morally wrong. But even that does not really work in this case. Not only do low-risk tobacco products not cost any productivity, but even smoking provides net benefits by feudalistic standards, generally allowing people to finish their working life, and then taking away some of the retirement years when they are just a drain on resources. Plus, all of these products enhance productivity for most people. Thus even fascists and neo-feudalists are hard put to ethically justify an “endgame”.

But not “public health”, or even public health. Because their underlying ethic — one that has never been accepted by any society and is impossible to defend as an ethical rule based on any moral system or empirical observation — is that the only objective is keeping all these bodies “pure” and walking around as long as possible. This roughly describes the goal of many a computer game, but it is not the actual preference of any people nor of any free society. Indeed, if you asked the people in public health who are capable of understanding the question (which is a minority, but not a tiny minority), “what is the underlying ethic or objective function you are working in pursuit of,” approximately none of them would articulate this absurdity. If you articulated it to them, most would agree it is absurd. Yet they would turn around and continue to make pronouncements and recommendations based on exactly that implicit objective function. They do not even realize they are implicitly basing their professional lives on an indefensible ethic because their professional culture denies them the language to question it and few are intellectual and honest enough to think beyond their profession.

Of course, this is not the story for all of them. An insightful and nicely apropos comment from Brian Carter just appeared on one of my posts from over a year ago (this blog is far more like a scientific journal than a bulletin — most of the older posts are just as useful now as they were the day they appeared, so people should still be reading and commenting on the archives). The commentator made the observation that the tobacco control extremists are driven by a moral zeal which causes them to genuinely believe that those who disagree must be stupid, dishonest (a version of which is “bought off”), or evil. I will offer a corollary to this: If there are no other possible explanations, then expressing disagreement — including in the form of refusing to obey the behavioral diktats — is, in itself, sufficient evidence that those who disagree are unworthy of consideration. A neat little package.

The commentator goes on to indirectly suggest that lying about the evidence is an extension of this from the people to science. My further extension of that is that while those people are frequently guilty of overt ad hominem attacks, it turns out that their lying about the science is arguably always, at its core, ad hominem. That is, any analysis or results that do not support the One True Message can only have been written by someone who is stupid, dishonest, or evil, and thus need to be ignored because of the character of the author. Similarly, anyone questioning the public health grandees on social media, no matter how reasonable or polite, is insulting them by the very act of being a stupid, dishonest, or evil person who dares speak to them.

This is the logical and inevitable (through predictable subconscious processes) extension of the underlying public health pseudo-ethic: The longevity and purity of bodies is the only goal that matters. Sometimes the annoying actors who occupy those bodies want to do things that are contrary to the goal, at which point they need to be forced, cajoled, or tricked into doing the right thing (compare: insects sometimes want to eat the crops, and they need to be manipulated into not doing it). But now some of those people are not merely quietly taking bad actions; they are actively speaking up against the public health goal and those who pursue it. As such, they are no longer just automata who need to be reprogrammed (without sympathy for their preferences, but also with no more personal hatred than one directs at the weather). By speaking up, the public have become the active enemies of the goal of public health.

Public health professionals — and this is not just the extremists but most everyone who exists in that culture — are so narrow-minded that even this obvious contradiction is not enough to make them realize the fundamental flaw in their worldview.

So the actual people who make up the public go from being ignored by “public health” to being genuinely hated. And with that, the temperance nuts find their home, not so much because they destroyed public health, but because public health made its way to them. They always hated people, thinking of them as sinners who needed to be controlled. The rest of public health joined them in this hatred when the public started rebelling against their pseudo-ethic and the grandee opinion leaders in the field redoubled their defense of it because they are not capable of seeing its absurdity.

It is easy to despise “public health” for what they do. But it is a different matter if you can understand what it looks like from the inside and how they got there. Once you understand that, you can still despise them for what they do, but you might want to consider despising them even more for how they got there.

[Update: a breezy follow-up on this that provides some comic relief and a fairly wonkish follow-up about how the medicalized view of public health results in the fetishization of inappropriate study methods.]