Monday, 22 September 2014

Public Health's Road To Our Serfdom

Another busy week beckons at Puddlecote Inc including a trade show where I'll be looking at delicious vehicles which - although innovative and very sexy (for some of us) - are far from practical. I often think Jim Bowen should be the salesman, arm round your shoulder saying "just look what you could have run if you were bankrolled by the Saudi Royals and overhead was irrelevant".

In the meantime, if you haven't read it already, I highly recommend you sort yourself a bevy of your choice and get stuck into an incredibly illuminating essay by Carl Phillips on the history and evolution of modern public health since the 1990s. The full text is here but, by way of a teaser, these excerpts might resonate strongly with regular readers (American spelling alert).
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. 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.
This denial of the scientifically-proven benefits of moderate drinking, I don't need to remind you, is just as prevalent today.

On the Ashton saga, Phillips writes:
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.
And on 'public health' emphasis on longevity over general welfare:
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. 
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.
Do go read the whole thing here, it's a real eye-opener.