Review essay published in The Independent Review, Vol. 4, No. 2 (Fall 1999); also available in a pdf format. Edited version reproduced in the National Post/Financial Post, October 2, 1999, under the title "Fascism and the Campaign to End Smoking". See also Proctor's reply and Lemieux's response in the National Post.
From the vantage point of a late-twentieth-century observer, the public health policies of the National Socialists who ruled Germany from 1933 to 1945 seem surprisingly modern. Those policies are illuminated in Robert N. Proctor's most recent work, The Nazi War on Cancer (Princeton: Princeton University Press, 1999), which documents the war on cancer and other public health campaigns by the Nazis. A historian of science at Pennsylvania State University, Proctor has written extensively on medicine, public health, and their relations with politics and, especially, with National Socialism.
The Nazi government was known, and admired, for implementing the most progressive public health policies in their time. State-of-the-art research and regulation were applied to occupational, environmental, and lifestyle diseases. Cancer was declared "the number one enemy of the state." Nazi policy favored natural food and opposed fat, sugar, alcohol, and sedentary lifestyles. The existing temperance movement against alcohol and tobacco became more active under the Nazis, who were involved in what Proctor calls "creating a secure and sanitary utopia."
Not surprisingly, American narcotics officials of the time admired the Nazi war on drugs. Today, admiration would probably go in the other direction.
The longest chapter of Proctor's book is devoted to tobacco, "a focus justified," explains the author, "by the startling fact -- heretofore unnoticed -- that Nazi Germany had the world's strongest antismoking campaign and the world's most sophisticated tobacco disease epidemiology" (pp. 9-10). It is well-known that Hitler himself was a rabid antismoker, but the antismoking movement and interventionist public policies of the Nazi area involved much more than Hitler's personal whims. Tobacco was attacked as a "relic of a liberal lifestyle" and as "masturbation of the lungs." It was in Nazi Germany that medical researchers, some with strong Nazi connections, first established a statistical link between smoking and lung cancer. Antismoking crusaders published magazines like Auf der Wacht (On Guard) and Reine Luft (Pure Air). Half a century before the Environmental Protection Agency enrolled junk science against "environmental tobacco smoke," antitobacco activist Dr. Fritz Lickint coined the term "passive smoking." (He also thought that coffee was a carcinogen!)
Many antismoking controls were enacted, including restrictions advertising and bans on smoking in many workplaces, government offices, hospitals and, later, in all city trains and buses. Women could not legally purchase cigarettes in certain places. "The German woman does not smoke," proclaimed a Nazi slogan.
In 1941, the Institute for Tobacco Hazards Research was created under the direction of Karl Astel. A dedicated Nazi who committed suicide in April 1945, Astel thought that opposition to tobacco was a "national socialist duty" (p. 209). As president of the University of Jena, he banned smoking in all university buildings. It is at Astel's Institute that Proctor traces the most path-breaking scientific work on the relations between smoking and cancer.
Proctor is puzzled and distressed by the fact that "Public health initiatives were pursued not just in spite of fascism, but also in consequence of fascism" (p. 249). But his book is weak on the analysis of this issue: in the closing chapter, where he tries to address it, he does not go much farther than stating that German fascism was a complex mixture of the good and the bad. Fortunately, the extensive documentation provided by the author does gives us the means of pushing the analysis beyond where he left it.
Let us recall that fascism is based on the subjection of the individual to the collective. As Benito Mussolini wrote about the twentieth century, "For if the nineteenth century was a century of individualism, it may be expected that this will be the century of collectivism and, hence, the century of the State" (Italian Encyclopedia 1932). The German brand of fascism, National Socialism, was characterized also by racist (as opposed to purely nationalist) beliefs. Let us recall further that, everywhere in the West, public health doctrine has drifted from public-good concerns, such as sanitation or contagious diseases, towards a frontal attack on individual choices and politically incorrect lifestyles (see my review of a book by Jacob Sullum's For Your Own Good, in The Independent Review, 3 [Winter 1999]: 460-465).
The relationship between fascism and public health is probably more symbiotic than Proctor admits. After reading The Nazi War on Cancer, the careful reader will be well positioned to understand why fascism requires strong public health policies. For the fascist State needs "valuable human material" -- or, as we would say today, healthy "human resources". Nazi slogans reported by Proctor are more explicit than what present-day crusaders would dare to employ: "Your body belongs to the nation!" "You have the duty to be healthy!" "Food is not a private matter!" Again anticipating today's health fascists, the Nazis' National Accounting Office outlined the so-called economic costs of smoking. Erwin Liek, sometimes called the father of Nazi medicine, thought that curing cancer required moving from "care of the individual" to "cancer prevention on a large scale -- for the entire people" (p. 25).
The public health mixture becomes more powerful with the added ingredient of racism supplied by the German brand of fascism. Public health campaigns contribute to the preservation not only of a population of taxpayers and conscripts, but also of the "German germ plasm." But this additive was not really required, as collectivism would have sufficed: "Germany's physician-führers," Proctor notes, "were less concerned about the health of the individuals than about the vigor of 'the race,' the so-called folk community" (p. 122).
Proctor takes care to distance himself from libertarians who would see fascism's invisible fist in today's repression of smoking: "My intention," he writes, "is not to argue that today's antitobacco efforts have fascist roots, or that public health measures are in principle totalitarian -- as some libertarians seem to want us to believe" (p. 277). This is just logic: if F (fascism) implies P (public health), it does not follow that P implies F. Of course.
But society does not live by logic alone, and one must inquire whether the logic of human action -- what Ludwig von Mises called "praxeology" -- traces institutional connections that tie public health and fascism in closer ways. Besides the fascist Leviathan's need for healthy subjects, I suggest that still other connections help to make sense of the disturbing evidence produced by Proctor.
One such connection is that both fascist policies and the modern public health ideology require a powerful state. State power is the common denominator, and a necessary condition, of both fascism and strong public health controls. Proctor reminds us that public health concerns were well known in the Weimar period and that the world's first state-supported anticancer agency was founded in Germany thirty-three years before the Nazis gained power. But, he writes, "What was new in the Nazi period were augmented police and legislative powers to implement broad preventive measures" (pp. 21-22). The police powers implied by fascism allowed the public health ideology to show its real nature.
The Nazi state apparatus had a "Reich Health Führer," with which office the name of Leonardo Conti, a strong antitobacco activist, remains associated. Under Conti, central registries had been established for many diseases and addictions. Nazi Germany was a transparent society, where individuals were prevented from hiding their lives from the state -- as absurdly illustrated by the 1938 ban on attic storage. Thousand of "registered" alcoholics felt victims of the sterilization program under the Law for the Prevention of Genetically Diseased Offspring. While many of the health fascists were prosecuted and condemned at Nuremberg, Conti escaped by hanging himself in his cell.
Thus, fascism naturally leads to public health tyranny, which in turn requires extensive state powers. Such is the logic of political institutions and the growth of state power. The main danger of the present public health movement does not lie in its fascist roots so much as in its capacity to justify and call for tyrannical government power.
Perhaps there is, in the moral field, a neat connection between the morality of an action and the goodness of the intentions underlying it. But, contrary to what Proctor seems to assume, there is no such correlation between human intentions and their social consequences. Since Bernard de Mandeville and Adam Smith, economists have appreciated that egoistic intentions can lead to good consequences for others. Similarly, good intentions can lead to undesirable consequences: as Friedrich Hölderlin wrote, "What has always made the state a hell on earth has been precisely that man has tried to make it his heaven." It is therefore not surprising that the good public health intentions of the Nazis had some awful consequences; or that such a bad ideology as fascism lead to some good consequences in terms of public health.
Or did it? Can we say that Nazism produced good public health measures? Perhaps, but only if we are blind to the costs they imposed on individuals. In fact, there are no public health consequences that are good in themselves regardless of their costs. Even if we accept that smoking contributes to lung cancer, this does not justify prohibiting adults to do what they want with their own lives. Against the twenty thousand German women who perhaps were saved from cancer by Nazi paternalist policies, one has to count not only the aggressions and deaths brought about by the political power necessary to effect this outcome, but also the cost to these women in terms of their own liberty and dignity.
Another issue looms behind Proctor's description of German life under the Nazis. Despite the tyrannical powers of the state, despite even the war, power was never completely centralized in Germany, contentious issues continued to be debated (at least within the Aryan tribe), cancer research was pursued, and the tobacco industry fought tooth and nail against the prohibitionists. Physicians cooperated with the regime, most often willingly, just as Christopher Browning's "ordinary men" murdered Jewish women and children (Christopher R. Browning, Ordinary Men: Reserve Police Battalion 101 and the Final Solution in Poland [New York: HarperCollins, 1992]). In other words, life maintained an appearance of normality. Just as it does today.
Of course, there is a difference of degree between the Nazi tyranny and the quiet administrative tyrannies under which we now live, but perhaps future observers will wonder how, at the end of the twentieth century, an apparently normal life could coexist with the accelerated onslaught on our liberties.
Despite his lack of a firm grip of political and economic issues, despite his naïveté about Leviathan and public policy -- or perhaps because the apparent objectivity that may be conveyed by these shortcomings --, Robert Proctor has produced a remarkable piece of scholarly research that is bound to influence public health debates.
Buy Smoking and Liberty by Pierre Lemieux at Amazon.com. Original French version also available.