Early in my anesthesiology career, I took care of an elderly man who needed knee surgery but who smoked like a chimney. The surgical team feared he would suffer the usual smoker’s complications, so we told him to stop smoking a week before his operation. He refused. In the end we reached a compromise: On the day before surgery he would get by with nicotine patches.
After surgery we noticed him moving all around in bed, craving nicotine, as he had yet to receive his patch that morning. This was actually a good thing, as he risked forming blood clots if he remained immobile. We decided to deny him his patches for a few days to keep him jumpy until he could start physical therapy. Unfortunately, he tricked us: He found a way to sneak cigarettes into his room. His renewed smoking probably caused his incision to heal poorly, since the carbon monoxide in cigarette smoke interferes with oxygen unloading in the tissues. Nevertheless, when I took away his cigarettes he told me to go to hell.
The story is a metaphor for today’s counterproductive policy toward e-cigarettes. Companies like JUUL Labs have created an e-cigarette substitute for smokers to “vape.” Although the substitute contains nicotine, it lacks the carcinogens and carbon monoxide found in “real” cigarette smoke. Despite improvement over traditional cigarettes, many public health experts oppose vaping, thinking it represents more of a gateway to cigarettes than a liberation from them. Nor does the FDA allow e-cigarette makers to advertise their products as being safer than traditional cigarettes. This has caused the public to mistakenly view both products as equally bad.
E-cigarettes are like the nicotine patches in my patient story: While it is best for people to abstain from all cigarettes, better that they use a less dangerous form. The public health activists are like the surgical team that denied the man his patches: In their quest to bring perfect health, they sometimes end up causing worse health. The average American is like my patient: resentful toward those who tell him or her how to live.
Yet my story is also a lead-in to a major difference between doctors and public health activists that has consequences for our politics: Doctors tend to be far more humble than public health activists about what science can accomplish.
I and the other doctors on the surgical team referenced above soon recognized our mistake. We forgot that the foolishness of human beings is limitless; so is the malevolence of chance. The unexpected always happens. In hindsight, we should have just given the man his patch.
Real life often pushes doctors to be practical in this way. Doctors respect science, and most of what they do is anchored in science; but they will ignore science if the situation demands it. In my anesthesiology practice, for example, patient attitudes often force my hand in ways that science would consider suboptimal. In one case I used a breathing tube instead of a facemask to give anesthesia because the patient feared the mask’s pressure on her face would give her wrinkles. The patient had a history of asthma, which made a breathing tube risky, yet she was so nervous about her appearance that I relented. Human beings have certain repetitive characteristics, without which practicing medicine would be impossible; yet each patient has his or her own psychology and even physiology, and this sometimes makes the constancy and logic that one hopes for in medical practice impossible.
Ironically, while public health has a weaker link to science than anesthesiology, it is less humbled by science’s limitations. Indeed, lack of humility has emboldened public health to insert itself into practically every conceivable public policy debate. Along with its traditional menu of concerns, including sanitation and immunization, the public health field now voices opinions on such issues as gun control, mental health, drug abuse, domestic violence, social justice, gender equality, sustainability, wealth redistribution, children’s day care, and foreign policy.
This is arrogance of the long-sighted kind. Public health activists drape themselves with the scientific method, declaring, “Why should not a method of investigation that has succeeded so well in solving problems in medicine be used to improve people’s well-being in a social, ethical, and political sense?” Because public health has a bona fide link to science, through medicine, which no social scientist can lay claim to, it has transformed itself into science’s emissary to policy debates once thought far removed from science. The fact that almost every life problem spills over into the public realm eventually, while also touching on somebody’s physical or mental health, makes public health’s portfolio potentially limitless. Not even social science claims such a range.
Yet public health advocates also reveal arrogance of the shortsighted kind. Vaping is a case in point. Public health experts rightly express concern over vaping’s new popularity among teenagers, as well as over the tardiness of e-cigarette manufacturers in addressing the problem. But while e-cigarette use has increased among young people, regular cigarette use has declined. Perhaps a world without any e-cigarettes might have led to perfect success: a decline in regular teenage smokers and zero teenage e-cigarette smokers.
Then again, everything I know about human nature, culled from my experience as a doctor and as a teenager decades ago, tells me that a fixed percentage of teenagers will partake in vice. Saint Augustine wrote as much 15 centuries ago in his Confessions when he described how he and his friends perversely stole and destroyed good pears just for the fun of it. Without e-cigarettes, the rate of regular cigarette use among teenagers would probably have stayed the same; one vice was simply replaced with another—albeit a safer one. Yet rather than work with this reality of human nature, the public health establishment continues to fight vaping in the spirit of a crusade.
Ideology and Arrogance
Public health’s special position in health care has given rise to this crusading spirit and to its new aggressiveness in public policy. Let me explain how.
In 1767, Sir George Baker became the first exemplar of modern public health. Using the scientific method, he traced the origins of a colic epidemic in Devonshire, England, to lead poisoning conveyed through the common cider people drank. Baker’s discovery highlights how public health differs from most other professions now orbiting medical science: Public health’s connection to science existed at the outset.
Nursing, social work, and clinical psychology all lack this early connection. Until the second half of the 20th century, the nursing profession championed compassion and selflessness over science. Social work in its early years championed the volunteer with a “good heart.” Clinical psychology’s status rose only after mid-century, when the field embraced the scientific model of mental illness and demanded doctorates of its practitioners. Long before these other fields had discovered science, or even started working with data, public health experts were on par with doctors, refining the science of epidemiology and applying bacteriology to prevent epidemics.
Public health is unique in a second way: nurses, social workers, psychologists, and doctors deal with individuals; public health experts deal with whole populations.
Individuals, like all real things, have resistance; they do not reliably conform to abstract principles or universal categories. Every nurse, social worker, psychologist, and doctor knows this limits science’s applicability. Because public health experts deal with whole populations, they are less likely to see how abstract scientific principles can fail. A public health expert might say, “We must fight cigarette addiction to improve health.” The phrase can be taken for truth because it evokes no precise image, and because the expert who utters it does so in good faith. But the policies the phrase inspires do not necessarily end cigarette addiction. Why? Because there is a divergence between words and things, between the scientific principle and the reality of individual human behavior. A simple phrase does not represent with sufficient exactitude the complexity of addictive behavior expressed by any one person—as most social workers, psychologists, nurses, and doctors can attest.
These two historical tendencies in public health combine to make the field both arrogant and ideological, relatively speaking.
Arrogant because public health experts do not watch their science fail on a daily basis. Because they work with large populations rather than with individual cases, public health experts often think with words—for example, the American Public Health Association’s (APHA) goals to “reduce global childhood mortality” and “support global food security.” Goals like these are easy for the thinker with words; the delay between error and the serious consequences of error—a very short timespan for an anesthesiologist—is too long for the public health expert to learn humility or even responsibility. After articulating a principle, the public health expert sees nothing go right or wrong for years, if ever, and so the value of the words can only be judged by their good intentions. When the entire planet becomes a platform for action, and the desired goals verge on being utopian, the issues themselves start to lack physicality. The public health expert is thus tempted to believe that everything has been done when only words have been spoken.
In addition, among sociologists, social workers, and politicians, public health experts are often the only people in the room who can claim a real connection to science. Because many Americans think science is the last word on the art of thinking, public health’s historical connection gives the field cachet.
Public health is ideological because all ideologies contain an element of hope and aspiration that can only be dampened by contact with reality. An ideology is a big set of ideas, a sweeping philosophy relevant on a large scale and for a long period of time. It thrives by ignoring details; it is so simple in its explanations that a single slogan can sum it up. Individual cases with particular details detract from the smoothness of an ideological system. Because public health experts do not manage individual cases, reality is less likely to quash their ideological enthusiasm.
Ideology plays a role in other health care fields. For example, in the 19th century, the new social category of “childhood” led to the establishment of pediatrics. Family practice arose as a specialty in the 1960s when laypeople pressured doctors to recreate the cozy physician generalist of yesteryear. But the very nature of what doctors do—care for individual patients—curtails their range of action. It makes no sense, for example, for a doctor to expound on foreign policy. Public health, on the other hand, has potentially no limit to its portfolio. The only limit is imposed by ideology itself.
During the 19th and first half of the 20th centuries, two ideologies limited public health’s range. The first ideology was the division between prevention and cure, which drew from the larger well of modern ideas that divided state and individual, public and private, politics and economics, and fact and value. Public health became synonymous with prevention, through state action, in the form of sanitation measures, garbage disposal, and quarantines. According to the ideology, since the state prevents mass armies of soldiers from invading the body politic, it should do the same against mass armies of germs. In other words, “prevention” is legitimately concerned with issues beyond any one individual’s control. “Cure,” on the other hand, involves that aspect of medicine that individuals can (supposedly) control, such as heart disease or broken bones. Curative medicine, or “private health,” became the preserve of doctors. For most of the 19th century, public health experts carefully stayed on their side of the line.
“Negative freedom” was the second ideology to limit public health. It defines freedom as letting an individual do whatever he or she wants. For example, letting a person go to McDonalds to eat a Big Mac, because he or she wants to eat a Big Mac, is an act of negative freedom. Based on early modern political thought, the ideology restrained government from telling people how to live. During the 19th century, public health experts were wary of violating the concept.
In the second half of the 20th century, the two ideological bolts holding public health in check exploded. The rigid division between prevention and cure, which made little sense from a medical point of view in any case, collapsed along with the other divisions in modernity. Society’s health and an individual’s health became the proper concern of public health.
Meanwhile, negative freedom gave way to the idea of “positive freedom,” which says that people are free only when they are being true to themselves. According to the new ideology, a man going to McDonalds to eat a Big Mac is not free; he is a slave to his desire for Big Macs, which he knows are bad for him. By keeping the man from going to McDonalds, public health experts insist they are making him free.
The stage was set for public health to insert itself into almost every policy debate imaginable, and to claim to know what is best for every person.
Public Health Everywhere
Several years ago, I met a young woman in a public health program who was starting up a research project. Although she had spent most of her life studying in school and before that, hanging out at the mall with her friends, she wanted to demonstrate the benefits of marital counseling on “family dynamics” and “mental health.” She asked me if I knew any people who might serve as subjects for her study. Teasingly, I replied yes, that I knew a man who was a doctor like me; he was also a poet; his name was Zhivago. Although he was married and had a child, with a second one on the way, he was having a fling with a woman named Lara. I noted that Zhivago’s life situation was pretty hectic, and that his neighborhood was going through some rough times.
The public health student brightened and said these people sounded perfect for her study. She thought Zhivago might be experiencing “situational anxiety” common during a “mid-life crisis,” which would explain his need to go outside of his marriage for “validation,” while Lara, she said, probably had “self-esteem issues.” She felt certain that Zhivago’s wife was “depressed.” All in all, she believed counseling would help them get their lives back on track.
That the young woman had never heard of the book (or movie) Doctor Zhivago surprised me. Yet her supreme confidence surprised even more. With the few mental health principles she had learned in public health school, she felt capable of solving the great intractable love triangle of 20th-century fiction (Zhivago, Lara, and Tonya) that was carried on amid that “pretty hectic” situation known as the Russian Revolution.
Although she knew the basic principles of mental health classification, her interest in isolated phenomena and the particular details of the individuals was conspicuously absent. Nor did she have any real life experience of her own to offer. Still, she was more than ready to slot Zhivago, Lara, and Tonya into diagnostic categories before hearing more about them. When I told her about Lara’s husband being away in the army and Lara’s first affair with a much older man, her eyes glazed over. Indeed, the more singular the phenomena, the more she lost interest. It was a symptom of the ideological state of her mind, and of her arrogance.
One finds more of the same on the APHA policy webpage. Peruse the topics and almost every major policy debate today is joined eventually, including debates over tax rates and the Israeli-Palestinian conflict. Public health feels entitled to comment on all of them, since each issue touches on someone’s health eventually, much the way that every person, one way or another, causes someone else trouble by dint of simply existing. Much of the commentary suggests ideology more than expertise, usually of the progressive kind. But progressiveness is not the problem. The problem is the false syllogism that encourages public health experts to speak out on all these issues.
For example, many economists spend their careers studying poverty and the ramifications of state-directed wealth redistribution. It’s a complicated issue. Public health cites mental health studies to enter the debate. One study says that, “poverty taxes people’s brainpower,” or, as the APHA newsletter puts it, “It’s just thinking about concerns about financial issues that leads to cognitive impairment [among the poor], so that itself is very powerful.” This is a stilted way of saying that poor people have a lot on their minds.
This simple truism does not need verification; nonetheless public health verifies it in studies structured according to the scientific method. Public health even uses a scientific name for the stressed out mind: “cognitive impairment.” This gives the truism the aura of science. Public health then frames the poverty debate as a question of health, which commands attention. In the end, public health insists that its favored solution, wealth redistribution, is the most medically sound.
This is shallow thinking. Misplaced pride accounts for some it. The scientific method is based to a high degree on intentional ignorance, as investigators purposely isolate certain details and leave out all the rest. This is why astronomy, physics, and chemistry are so amenable to the method. The quantities involved are so vast or so tiny that many details must be left out, making the experiment clean. Still, while supposing such isolation to be accurate, investigators suppose what is false. This is not a problem in hard science—an unreal condition is created; a formula results; the formula is then tested under conditions that replicate the original state of ignorance. But when human beings are involved, the details cannot be shut out so easily—and there are many such details. An infinite array of feelings, drives, and memories prevent the artificial isolation needed for the scientific method to work. Poverty alone is a complex state of mind. This is why the scientific method cannot reliably predict human behavior or any person’s response to a given stimulus. And yet the APHA says that its policy approach “reflects the latest available scientific research.” By pretending that poverty can be approached scientifically, public health pretends what is ridiculous.
In a second example, the 2018 APHA policy statement calls violence a public health concern. Violence has been a social problem for many thousands of years, but we are led to believe that the APHA has found the way forward. It calls for “encourag(ing) community health programs to start programs that detect and interrupt the transmission of violence using professionally trained workers,” addressing violence “using a trauma-informed and culturally competent approach,” calling on “federal, state and local governments to invest in public health approaches to violence prevention,” and “establish(ing) an active surveillance system for monitoring violence in communities.” The policy statement also includes references to “marginalized populations” and “law enforcement violence.”
The APHA may speak of a link with science in other parts of its platform, but here they do not choose their words according to science; they choose them according to the effect they wish them to have. The turgid clauses; the words themselves, heavy on the Latinisms; the pretense of calm, matter-of-fact omniscience—all these carry the reader forward. The words possess the flavor of erudition, and by combining them with ideological catchwords and occasional references to science, the policy proposal reaches its object, which is to overwhelm readers and give them confidence that violence is a fixable problem, just like dirty drinking water.
The APHA webpage discusses other problems such as equity, gun-related suicides, and clean energy. The paragraphs devoted to these issues share the same structure as the one on violence. The phrases seem to interlock spontaneously; and while they are all formed on a similar model, they are subtly adjusted to make each policy pronouncement seem fresh. The whole document presents in logical order a list of ills that have plagued humanity for more than 2,000 years.
Yet despite the document’s polish it carries one great risk: the risk of unreality. Such ills cannot be fixed easily if at all, which most people not mesmerized by a caricature of science recognize.
Public health activists are clever enough to understand the scientific method, but they are not clever enough to understand its limits. Their minds are crowded curiosity shops where science, ideology, and hubris all find a place.
A college student drinks gin and soda and gets a headache. Then he switches to rum and soda and gets another headache. Perversely, he blames the soda for causing his headaches. In fact, the soda was only associated with his headaches. The real cause was the alcohol.
It is ironic that public health activists fight vaping, since regular smoking is one of the few lifestyle factors convincingly established as a cause of common and serious disease. Smoking causes lung cancer and heart disease, sun exposure causes skin cancer, and sexual activity that spreads the papilloma virus causes cervical cancer. Most other causations mentioned in connection with lifestyle are mere associations—not unlike the college student’s soda-induced headache.
Although epidemiologists admit this, public health as a field rarely advertises the point.1 There is hypocrisy at work here. Public health emphasizes its link to science, but when it wants to unnerve people with a mere association, it conveniently plays down the association-causation distinction.
This happened during the 1990s debate over silicon gel breast implants. An association between silicon gel breasts implants and suicide (and substance abuse) was advertised. The public health establishment disliked breast implants for a variety of reasons, many of them ideological—for example, the notion that women were putting themselves at risk in the service of the “beauty myth.” When people believed implants caused suicide and substance abuse (and public health experts rarely disabused them of this notion), public opinion hardened against the product. In the end, the implants were restricted for a decade, until new evidence vindicated them. Public health experts never stated in so many words that they were being ideological—they said they were being scientific. They spoke of everything but that; and yet, they were that.
In smoking, regular cigarettes cause disease. There is real science here. If vaping has serious risks, those risks have not yet been shown, let alone shown decisively in the form of causation. Then why the obsession with vaping, especially when cigarette smoking is clearly so dangerous? Writers have mused that public health is in bed with the tobacco companies, who fear vaping will cut into their cigarette sales, or Big Pharma, which peddles its own nicotine products.
There may be a simpler explanation. Public health activists know the difference between fact and fantasy, but they believe the fantasy—that vaping is as bad as smoking—because they themselves have invented and ornamented it. And who is so strong as not to believe his or her own invention? Even expert scientists have difficulty. All that is in agreement with one’s personal desires seems true; all that is not makes a person angry. This is simple, garden variety confirmation bias at work. Although public health activists have a strong link to science, they are also invested in ideology more than most health care professionals; unlike scientists, who may question their hypotheses, they feel allegiance to a set of ideas and are stirred more emotionally as a result. Science works best when it is indifferent to the system it invents; it works worst when it clings to it passionately. Ideology and arrogance prevent the necessary disinterestedness that is the hallmark of good science.
Public health activists need to change their mindset and hence their ways, and not just on the issue of vaping. Because they have the scientific method, they have logic on their side, which emboldens them to think they can speak authoritatively on almost any issue. Data is collected, numbers get punched in, scientific-sounding terms are invented, and all the while activists fail to realize that they are making no progress despite their efforts. The scientific method gives them an agility that others lack, but it also gives them the bad habit of believing that all is accomplished when they have indulged in a process of reasoning that has the aura of truth.
1For a discussion see Curtis Brainard, “What’s Healthy? Don’t Ask Scientists, or the Press Either,” Columbia Journalism Review, September 19, 2007. In the piece, writer Gary Taubes reports: “The appropriate question is not whether there are uncertainties about epidemiologic data, rather, it is whether the uncertainties are so great that one cannot draw useful conclusions from the data.”