Alright. I'm gonna now spend much of the remainder of the day on what I think
is one of the most important issues certainly we'll talk about today.
That's, "Why is public health so often such a contentious field?"
Why do we always get in battles over things?
And why do I say
you're really not going to have any public health problem,
or any public health resolution of any consequence,
unless you're dealing with these contentious forces?
So, here you see the reasons.
I'm gonna go through each one individually so I won't read them
to you right now. But I'm gonna talk about each of them in some length.
First: Restrictions on individual liberty.
A lot of what public health does is
trading off the rights of individuals
for the health interests of the community.
There's a huge amount of that in our society, way beyond public health. I think,
one can say,
that the fundamental debate that's going on in politics today, this kind of,
the individual versus the community.
So, why do we have these restrictions on individual liberty? We have something
that years ago was called the "tragedy of the commons."
It was an interesting story in England
where they had a common grazing area for sheep. And, the problem was, everybody who had sheep
brought them all to this common grazing area. And in no time at all, there was nothing 0:01:28.410,0:01:.29.900 to graze on.
The sheep had eaten it all up, and the sheep got
sick and died because they
didn't get any food.
Well, that means when you've got this common property you have to figure out
how to deal with it--
how to restrict use, how to share use.
How do you come up with that?
This all relates these two terms, public goods and externalies, and we will come
back to that.
It's paternalism!
Paternalism is a very ugly word in the United States--the idea that
big brother is going to tell you what to do. You're an adult,
and you have the right information, you ought to be able to make up your own
mind about what to do.
And if otherwise you're told to do something, that's paternalism.
We have examples of that in public health, and they've been fought out for a long time.
Seatbelt laws.
If I wear a seatbelt in the car, I am protecting, predominantly, myself.
I'm not really protecting other people outside the car.
With the exception of people in the back seat,
wearing a seat belt is not protecting others inside the car very much.
If you're in the back seat of a car,
and you're not wearing a seat belt, and you have a
head on collision, you become a projectile, and you go straight forward,
into the seat where the head of the person in front of you. And there are
very serious fatalities that occur.
I guess all fatalities are serious.
There are fatalities... (laughter)
There are not many gradations of that. You're dead, or you're dead--
that occur simply because somebody in the back seat didn't have a seat belt on,
whereas the person in the front seat did.
But, in general, we're talking about a law here
that is for the community good,
even though individuals may not like it, and their freedom is restricted.
How many of you have--boy, they have to be even older than your grandparents--
grandparents, or great-grandparents, in their eighties, let's say,
who, when they get my car,
they won't buckle up unless somebody reminds them?
Yeah, quite a few of you.
I've got some friends in my poker game, a couple of them are in their eighties,
and they will not put the seatbelt on unless you tell them.
Those folks never wore seatbelts!
They were adults
well into their driving experience before seatbelts came around, and they
still don't like them as a result.
I didn't have seatbelts when I learned to drive. They weren't in the cars.
But, they came on early enough
that I got to the point
I feel kinda naked if I don't have a seatbelt on. I'm not going to
drive without a seatbelt on. I just never--and this has nothing to do with being in public health--
I've never felt safe without having a seat belt on.
The generational kinda phenomenon.
Those people,
the older folks, really feel like their freedom has been impinged upon by
requiring them to wear seatbelts.
Alight. We've got social norms and morals, sodomy laws. You know the list.
We have behaviors that directly affect other people. Now, think about this.
I don't think there's anybody in this room who would say we shouldn't have
laws against criminal activity like murder, rape,
and so on--at least I hope there's nobody in the room who thinks we shouldn't have those laws--
and that we shouldn't do something about it when somebody's out there
killing a raping people.
So, that just seems obvious.
But, aren't we restricting their individual freedom?
We are. It's just, the consequence of what they're doing with that freedom is so bad
for other people
that we say, "No deal. Can't do it."
Speed limits.
Traffic lights.
Why do we have those?
It's part of a social pact that says we're all going to be safer if we
give people the right of way because we stop at a red light.
How many of you have ever thought about the fact that you're out late at night,
you're in the middle of nowhere,
you come to a red light,
and you stop.
And you sit there, and you wait for it to turn green, when there's nobody within a
100 miles.
Right? How many of you have done that?
Alright. Everybody.
Now isn't that odd?
Nobody nearby.
We're all sitting there thinking, "Oh, maybe there's a camera taking pictures, or cop behind a
billboard," or something like that.
But, we've been very well socialized on that one.
And, at that particular point in time, that light isn't worth much.
But, as a general device, it's worth a lot. It makes driving a whole lot safer.
How many of you have noticed the--well, you all wouldn't have noticed because you haven't been in
Ann Arbor long enough, probably.
Ann Arbor never had the roundabouts.
Now, we're starting to see a bunch of roundabouts in Ann Arbor,
a terrific device that we finally figured out, and finally adopted from the Europeans
that actually reduces accidents-- or, excuse me, collisions--
quite a lot, and speeds up traffic flow without needing traffic lights,
in many instances.
So, there are lots of ways of doing this, but we all agree with this--
prohibiting drunk driving.
Again, nobody in here would say...
we should allow drunk driving. Now, we may have done it ourselves on occasion,
but we still think the law is right.
Banning smoking in public places.
Quarantining people with infectious disease. If you have a serious infectious disease
your public health department
has the right to a lock you up
if you will not stay in your own house by yourself.
In the event of a big outbreak of an infectious disease, if you're not willing
to stay put in your house,
they can lock you up.
They have that authority.
Why? Because of the communicability and seriousness of the disease.
We require immunizations for school enrollment. Think about this.
We require kids to enroll in school when they're five, or six, or whatever it is.
But, we say you can't enroll in school
unless you have these immunizations.
Kind of a double whammy there. You've gotta do both.
There are religious exceptions to that, but, in general, most of us get our immunizations.
Prohibiting various forms of pollution. Because, what are we going when we pollute,
when a factory is polluting?
It is messing up the environment for other people.
How about behavior that indirectly affects others--
motorcycle helmet and seatbelt laws? Again, the seatbelt laws are really affecting
you, yourself.
What's the motorcycle helmet law doing, if you have a law requiring the use of
of motorcycle helmets? Who's it protecting? How's it protecting others?
Any ideas?
Sir?...And costs more. That's right!
They're going to impose a cost on you.
You all will, shortly, have a homework exercise coming up. And, one of the
options relates to...one of the three options to which question you would
address--which policy.
And, one them has to do with Michigan's new
motorcycle helmet law
which, by the way, allows people over the age of 21, under various
circumstances, not to wear helmets.
And, it's a law that a lot of motorcyclists have fought for for
decades. I can't remember,
since I got here, a year in which there weren't demonstrations trying
to get rid of the
law requiring helmet use.
One part of the law--
they've gotta have extra insurance
to cover the extra costs associated
if they're driving and have a collision that creates problems.
Alright. Bans on illicit drugs. A lot of illicit drugs aren't doing much damage
to anybody except for the user, and if the user.
But, it bothers people.
Sodomy laws, abortion laws,
U-M campus-wide smoke-free policy. You can't smoke outdoors,
as well as indoors.
And it's only indirectly affecting people. I can think of several indirect ways it's
affecting them. May be a very good thing.
How about the debate over individual responsibility? This concept of blaming
the victim, as we put it in public health.
"Are people who suffer from a given problem at fault"
"for the problem--and therefore individually responsible for resolving it--"
"or are they victims who need and deserve (public) assistance?"
Think about this list.
Are people who smoke
at fault
because they smoke? Is it
their fault, and therefore it should be their problem, and we shouldn't be doing anything
publicly to aid them to quit?
It's just their own problem and they should know better?
Well, you know, people get addicted
by the time...Your age--I mean, you all are probably too old, at this point, to really start
smoking. You're not. You all are the tobacco industry's targets,
by the way. You're exactly a target--
18-24 year old age group,
because they're finding it much harder to go after kids now that the law is
starting to get on them for going after kids.
So, you all are their target. But, historically at least,
if you reach the age of 18, 19, 20,
and you weren't a smoker, you were very unlikely to become one.
So, you're usually getting addicted as a child-- frequently at the age of 12, 13, 14, or 15.
It's a very real physical addiction. It does all the stuff to your brain that
cocaine and heroin do. Actually, it does more than that because many more
smokers are addicted proportionately than cocaine and heroin users. Many more.
A much larger percentage.
So, is it these kids' fault that they're smokers?
I'm not gonna answer that one.
I don't have the answer. That's a matter of decision.
Think about these other problems in here.
The obesity epidemic. Is it simply that all of a sudden we got a lot more
people who are
doing the wrong things with regard to diet, exercise,
or are there social reasons that there's an obesity epidemic?
And, are there social interventions
that we should be thinking about to address the obesity epidemic?
We'll talk a lot more about that.
Economic interests.
There are often powerful economic interests that are hurt
by public health regulations.
Think of the food, alcohol, and tobacco companies.
Polluting firms that are told they can't pollute.
They're gonna be fined if they pollute.
How about healthcare insurers, hospitals, providers
who are told what they have to do, that they may not want to do.
Local retailers, such as restaurants and bars.
The smoke-free law in the state of Michigan that went in effect a couple years ago--
and in virtually every other state. Thirty states have these laws now--
the biggest opposition to them
are the restaurant organizations,
and the bar owner organizations. It turns out,
they probably--the restaurants certainly--make as much money, or more, by not allowing smoking.
But, some of them don't wanna give it up.
The bars' best evidence is that they, too, do a little bit better with no smoking allowed.
But, they think they're gonna lose a lot of money, and they're getting a lot of support
from the tobacco industry. So, we're combining two economic interests there, and that
becomes the opposition.
Without that opposition,
you would've had a smoke-free law in Michigan
years earlier. You would've had a smoke-free law in lots of states years earlier.
Any time you got a powerful economic interest, you have a powerful political lobby
that defines an awful lot of what goes on in this country.
What's, probably, the most important
political lobby in the United States right now?
NRA--National Rifle Association.
They've got lots of members, they've got huge amounts of money
that they put into the pockets of both Democrats and Republicans,
and they've been enormously successful. People are--
politicians are afraid
to go against the NRA because, you go against the NRA position on any issue,
and they're gonna put big money into your opponent's campaign.
They're gonna do their best to make sure you don't get re-elected.
That's the most important one.
There's another one. What are some other really important lobbies in the United States?
AARP,
which used to stand for American Association of Retired Persons.
Now, you all won't be impressed with this when you turn 50
but, I was impressed with it when my wife turned 50--she's a little bit older than I am.
The day she turned 50, she had an invitation from AARP
saying, "Join. Become a member."
Now, how do they know to get to that person exactly on the day they turn 50?
The day I turned 50,
no invitation.
Oh, don't feel badly for me.
I was already an associate member.
So, their information systems were sufficiently sophisticated that they knew
exactly when somebody is turning 50,
and exactly when to ignore them 'cause they already had them.
AARP does a lot of good things,
but it's an enormously important lobby, and it's one of the big reasons that you
folks may be in real deep trouble
when it comes to figuring out how we're gonna to deal with health care in the future.
Because we gotta do something about Medicare, which is a disaster.
We're gonna talk about that
in this class. It's a disaster waiting to happen, and everybody knows it.
We've got the data. We know when it's gonna go bankrupt. We can tell you
exactly when it's gonna go belly up.
And the AARP is making
darn sure that it's hard to reform it
because of all their
members 50 and older.
Economic interests. A couple of other affects. The cost burden tends to
fall on different people than does the benefit derived.
So much of what goes on a public health
is taking tax money
out of the wealthy ,the politically enfranchised population,
and making it pay for something that's going to go to the poor and politically
disenfranchised.
That's not a formula for political success,
But, it's where the problems are, and we've gotta figure out how to deal with it.
The politics of dealing with trying to have current costs, current expenditures,
for some abstract future benefit.
How many of you know the term discount rate--what a discount rate refers to?
Okay, not too many of you.
Take some economics, you'll know discount rate.
Discount rate
is basically saying people have a trade-off between the present and the future.
So, they'll, you know, trade off how much something is worth to them in the future and generate.
And, generally, things are worth more at present.
So, the discount rate shows how much you discount that future. Politicians, it's
often said, have a 100% discount rate beyond their term.
They don't want to spend money,
increase expenditures out of their city/ state/work/national budget
when they're not gonna have something tangible to show
to their electorate when they're up for election next time.
Public health takes expenditures today for benefits 10, 15, 20 years down the line.
That's tough.
There are morality issues in public health, and we all know this intensely felt
position: abortion, sex ed,
safe sex, clean needles, gay marriage, stem cell research. All of these are very hot issues.
One of the biggest challenges I find for many of my colleagues in public health
is to be tolerant of people who have different views.
So, on the abortion issue, most
people in public health--I think this is a fair generalization--
favor women's choice. I do personally.
But, I can understand that there are people who feel extremely strongly on the other side,
and they're not bad people.
And, it's not the wrong position
for them to take. It's just one of those tough issues where there are
big differences in how people feel.
And there is frequently a lack of tolerance within
lots of areas, including, in this case, public health when it comes to an issue like that.
Politics and science.
I'm not gonna go into each of these individually, but, suffice it to say,
that administrations--and this includes virtually every administration. You see
it more often in some than others--
often promote their own social and political agendas by specifically
interfering with science.
President Reagan
after AIDS was identified--HIV was identified--President Reagan said we are
not going to spend any research money
on AIDS because people have brought this on themselves.
It was the gay male,
and the IV drug user, and they were causing this problem themselves. They
have brought this problem one themselves.
We're not gonna do anything as a nation to deal with that.
Now, fortunately
he ended up reversing his position later on, and we start to see very large
amounts of money flow into AIDS research, and have had very great success
with much of it.
Sometimes you gotta have a particular policy position. I was Dean of this school a while ago,
and, at one point,
I got calls from AID, the Agency for International Development, and they
wanted to send people to talk to me about the fact
that we had a faculty member
who was doing research on population planning.
We had a whole group of people who were doing research on population planning,
but they're only asking about one
because AID funding was involved, and they didn't allow that at that
point in that administration.
That's a very clear interference with science. She wasn't causing
population planning to occur. She was doing science on it.
Litmus tests for high level appointees. You'll find some presidents who will not
allow a candidate for the Supreme Court
if they don't believe in their position on abortion, for example.
And so on.
So, suffice it to say,
that there are a lot of contentious issues. It's what makes this field so interesting,
but also difficult.
So, I'll leave you with these thoughts. Public health is certainly under-appreciated,
invisible to many,
underfunded and under-practiced.
It's hard.
It's very politically challenging.
It requires this very important mix of science and politics,
and it's important.