The moral maze of public health

Abstract

In response to various health and food-safety “scares” in recent years, the French government has invited its parliament to prepare legislation to create a central authority that will oversee public health and food safety. The new authority, which is to coordinate services hitherto dispersed throughout several government departments, will be similar to the US Food and Drug Administration.Similar thinking seems to have taken place at the headquarters of the Labour party in the UK, who seem set to be that country's next government. Labour intends to appoint a Minister of Public Health, distinct from the existing post of Secretary of State for Health. What would this Minister do? According to the Labour party, he or she would ensure that health effects are considered when the value of any new initiative—eg, the building of a new road—is considered. In addition, departments will be required to monitor the health effects of ongoing projects. The idea, Labour says, is not to create another layer of bureaucracy, but to break down barriers based on traditional interdepartmental rivalries.Compare the above sensible approaches to improving public health with a curious judgment last week at the European Court of Human Rights in Strasbourg. Three men had taken the UK government to court in an appeal against their conviction and imprisonment as a result of having indulged in consensual sadomasochistic acts in private. A previous appeal to the Law Lords in the UK failed by a ruling that consent is no defence to infliction of injury, even when the injury does not cause lasting harm. Last week's appeal failed when the majority of the Strasbourg judges ruled that the UK government was entitled to interfere in the private lives of the applicants in order to “protect public health and morals”. This judgment is interesting on two counts. First, it illustrates the worrying extent to which interference in private activity can be justified on grounds of “public” health; second, it is a reminder of the difficulty many powerful figures have in separating issues of health from issues of morality.Political squeamishness over so-called moral concerns has hindered, diverted, or halted numerous sensible public-health initiatives. A famous casualty of such political nervousness was the USA's last Surgeon General, Joycelyn Elders. She held that post during President Clinton's first term, and fell foul of the highly politicised religious groups of that country. Her commonsense and reasoned approach to basic public-health issues such as sex education for children proved to be too politically contentious for the President, and she was fired. The attempts to appoint an uncontroversial successor for Elders descended into farce, and the post remains empty. Last month saw a small-scale UK re-run of the Elders experience when an evidence-based review of sex education annoyed the politicians.Some commentators say that it is of little consequence that the USA has no Surgeon General, since the position, although high profile, nevertheless carries little power. They will find the article by Peter Lurie and Ernest Drucker in this week's issue (p 604) food for thought. Lurie and Drucker estimate the cost, human and financial, of the failure of the US federal government to implement a national needle-exchange programme in the early stages of the AIDS epidemic in the USA, despite the supportive conclusions of several government-funded reports. Would the advice have been followed had there been an outspoken, high-profile public-health advocate on Capitol Hill? Possibly not, but such an advocate might have ensured that the evidence was given continued prominence.Agencies similar to the FDA are not immune from political pressures, and ministers of public health will not be either, but they are steps in the right direction. To ask for public health to be removed from politics would be naïve, and we suspect that the best that can be hoped for public-health agencies is that they act in the public interest in a buffer role, protecting often uncomfortable facts from the distortions of gut-reaching politicians. In response to various health and food-safety “scares” in recent years, the French government has invited its parliament to prepare legislation to create a central authority that will oversee public health and food safety. The new authority, which is to coordinate services hitherto dispersed throughout several government departments, will be similar to the US Food and Drug Administration. Similar thinking seems to have taken place at the headquarters of the Labour party in the UK, who seem set to be that country's next government. Labour intends to appoint a Minister of Public Health, distinct from the existing post of Secretary of State for Health. What would this Minister do? According to the Labour party, he or she would ensure that health effects are considered when the value of any new initiative—eg, the building of a new road—is considered. In addition, departments will be required to monitor the health effects of ongoing projects. The idea, Labour says, is not to create another layer of bureaucracy, but to break down barriers based on traditional interdepartmental rivalries. Compare the above sensible approaches to improving public health with a curious judgment last week at the European Court of Human Rights in Strasbourg. Three men had taken the UK government to court in an appeal against their conviction and imprisonment as a result of having indulged in consensual sadomasochistic acts in private. A previous appeal to the Law Lords in the UK failed by a ruling that consent is no defence to infliction of injury, even when the injury does not cause lasting harm. Last week's appeal failed when the majority of the Strasbourg judges ruled that the UK government was entitled to interfere in the private lives of the applicants in order to “protect public health and morals”. This judgment is interesting on two counts. First, it illustrates the worrying extent to which interference in private activity can be justified on grounds of “public” health; second, it is a reminder of the difficulty many powerful figures have in separating issues of health from issues of morality. Political squeamishness over so-called moral concerns has hindered, diverted, or halted numerous sensible public-health initiatives. A famous casualty of such political nervousness was the USA's last Surgeon General, Joycelyn Elders. She held that post during President Clinton's first term, and fell foul of the highly politicised religious groups of that country. Her commonsense and reasoned approach to basic public-health issues such as sex education for children proved to be too politically contentious for the President, and she was fired. The attempts to appoint an uncontroversial successor for Elders descended into farce, and the post remains empty. Last month saw a small-scale UK re-run of the Elders experience when an evidence-based review of sex education annoyed the politicians. Some commentators say that it is of little consequence that the USA has no Surgeon General, since the position, although high profile, nevertheless carries little power. They will find the article by Peter Lurie and Ernest Drucker in this week's issue (p 604) food for thought. Lurie and Drucker estimate the cost, human and financial, of the failure of the US federal government to implement a national needle-exchange programme in the early stages of the AIDS epidemic in the USA, despite the supportive conclusions of several government-funded reports. Would the advice have been followed had there been an outspoken, high-profile public-health advocate on Capitol Hill? Possibly not, but such an advocate might have ensured that the evidence was given continued prominence. Agencies similar to the FDA are not immune from political pressures, and ministers of public health will not be either, but they are steps in the right direction. To ask for public health to be removed from politics would be naïve, and we suspect that the best that can be hoped for public-health agencies is that they act in the public interest in a buffer role, protecting often uncomfortable facts from the distortions of gut-reaching politicians.