Published in MD Canada, May-June 2004, p. 72. Also available in a pdf fac simile.
The Public Health State
by
Pierre Lemieux
The economic concept of “public health” is close to the traditional medical concept. It is concerned with contagious diseases and sanitation works, or other aspects of health that generate what economists call “externalities,” or spillovers to third parties.
The fashionable, contemporary concept of public health is very different. The World Health Organization defines health as “a state of complete physical, mental and social well-being.” The British government’s Public Health Electronic Library defines public health as “The science and art of preventing disease, prolonging life and promoting health through organized efforts of society, inclusive of all interventions designed to improve the health of the public.”[1] In “organized efforts of society,” society of course means the state.[2] Call it the Public Health State.
Public health insurance appeared first in Germany at the end of the 19th century, and followed in virtually all countries during the 20th century, including in Canada at the end of the 1960s. A demonstration of altruism towards the poor? Altruism is often deceptive. Lots of people gained, or thought they were gaining, from the creation of such regimes. The poor (who were certainly not altruistic!) were getting a free ride, politicians were buying support from the masses with the masses’ own money, and physicians were getting a free collection agency – or at least many thought it was free.
The Public Health State, however, is more than just public health insurance. It is one thing to be concerned with the health of the poor, and for doctors to dream, like everybody would, that what they deem important will be offered free to their customers without any cut in their own incomes. It is another thing to dictate to individuals what is important for them. But one leads to the other: the dream leads to the nightmare.
There are two reasons for this. First, once the state is financially responsible for everybody’s health, it will try and control lifestyles that drain the public treasury.
The second reason is paternalism. Paternalism is a natural sentiment for anybody who loves somebody else, or who believes he has knowledge that others don’t have. The problem comes with coercive paternalism. And when the state espouses paternalism, it cannot be non-coercive.
Through obscure political and bureaucratic processes, and in complicity with the subsidized public-health establishment, the Public Health State determines that some individual choices and lifestyles (smoking tobacco, taking drugs, not exercising, drinking certain kinds of alcohol, engaging in certain sexual practices, keeping guns for self-defence, and so forth) are not in the best interest of the choosers, and forces them to change their ways. The term “force” is not an exaggeration: behind any state intervention, armed men are standing by to deal with the practical dissenters.
The public health movement has become a sect. It ignores theories and evidence that don’t support its jihads, especially economic analysis. Guess why? The methodology of economics is based on individual preferences, on the fact that each individual makes his own trade-offs between costs and benefits, and on the idea that nobody can scientifically claim to know what is good for an individual better than the individual himself. Under the excuse of reducing some risks in life, public health crusaders want to crush lifestyles that they do not like. In doing so, they create other risks.
Many people find it paradoxical that the Nazis were running the most advanced Public Health State of its time. State-of-the-art research and regulation were applied to occupational, environmental, and lifestyle diseases. Nazi policy favoured natural food and opposed fat, sugar, alcohol, and sedentary lifestyles. The Nazis, says historian Robert Proctor, were involved in “creating a secure and sanitary utopia.” “Food is not a private matter!”, proclaimed a Nazi slogan.[3]
But is there really a paradox? The most powerful the state, the more it can take care of its people (i.e., of some of its people). And the more it wants to take care of its wards, the more powerful it has to be. When I raise the Nazi example, people who have reasons to feel in bad company blame me for “a cheap shot,” as if not talking about tyranny prevented it. In fact, it is an expensive shot because one does not get rewarded for warning one’s fellow citizens about advancing tyranny.
The Public Health State can only be authoritarian, even if it is under the name, or the excuse, of the people. In late 2001, Dow Jones reported that McDonald’s had been forbidden to sell Snoopy dolls in China. A Chinese state newspaper argued that the promotion “instigated a buying spree ... and seriously affected the physical and mental health of children and teenagers.”
If the state is responsible for everybody’s health and knows better than the individual how his health can be improved (“diet, lifestyle, and physical exercise… the wider economic and societal determinants of health,” as the British government says), and how he must trade-off costs and benefits, then of course it will coerce him for his own good, just like a parent does with his child.
From the caring state to social engineering and tyranny, theory and history suggest that the slope is steep and slippery. We are far from Hippocrates, who told doctors to, “make a habit of two things – to help, or at least to do no harm.”[4]
[1] At http://www.phel.gov.uk/ (visited February 6, 2004).