In 1975, I published a brief article in the American Journal of Public Health, titled, “Public Health: Alien Ethic in a Strange Land?” In that article, I noted that the prevailing theory for addressing the nation’s alcohol problems would be found by answering a simple question: Why are some people unable to control their drinking?
I noted that the question seemed obvious, almost self-evident. Most people drink. Most people drink without problems. Some people, however, suffer serious alcohol problems including alcoholism and its sequelae of cirrhosis, cancer of the esophagus, stomach, and so forth. Why does this unaccountable minority suffer problems when so many others do not?
I also noted that there was a growing body of epidemiological research that asked a very different question: why do some societies have more problems with alcohol than others? What causes the rates of alcoholism in countries, or states or regions to vary? These questions that focus on the varying rates or levels of alcohol problems receive a very different set of answers: the level or rates of problems with alcohol, from rates of cirrhosis to alcohol-related traffic crashes are related to the total amount of alcohol each society consumes. The more everyone drinks, the more alcohol problems we can expect. This equation has not been received as good news by the alcohol industry.
My brief article suggested that this public health approach to alcohol problems, also known as the per capita consumption or the alcohol control thesis, proposes measures to limit the availability of alcohol. with taxes, age limits, advertising limits and the alike. Alcohol problems arise from a multiplicity of societal arrangements that do not adequately limit total consumption of alcohol.
An accompanying article to mine argued that, despite the research findings, associations do not prove causation, and that we lack substantial means for limiting alcohol problems using traditional controls. The authors of the commentary, Bruce Vladeck and Robert Weiss, the latter being the dean of the school of public health at Columbia, clearly were concerned that the "public health approach" smacked of a return to the era of Prohibition, a time when the more rural and Southern regions of the country imposed their values on the rest of the county.
This alcohol control controversy, which erupted during the 1970s in the U.S., is still in limbo. The controversy eventually led to the dismissal of the new head of the National Institute on Alcohol Abuse and Alcoholism (he said the evidence was on the side of alcohol control policy).
In 1981 there was also the publication of the landmark study, Alcohol and Public Policy: Beyond the Shadow of Prohibition. This study, conducted under the auspices of the National Academy of Science, resoundingly affirmed the need for a strong and intelligent policy to control alcohol consumption and alcohol problems. Among the panel of experts, including myself, was a future Nobel Laureate in Economics, social psychologists, noted social scientists, and several internationally known epidemiologists and alcohol survey researchers from Finland who also participated in our proceedings. Alcohol policy remains a hot potato in this country.
Today, alcohol policy still remains a hot potato in this country. In 1990 or so, when I had moved to New York and worked as a deputy commissioner for policy of the state department of health, the governor's office called and asked me to meet
In my article in 1975, and in another article published the next year, “Public Health as Social Justice,” in the health services research journal, Inquiry (now defunct), I argued that public health was an ethic of social justice, and social justice for our nation's health was then, and in many ways still is, an alien ethic in a strange land.
I contrasted social justice with market justice. I noted that in both approaches many of our problems in health are rooted in social arrangements and conditions that protect and benefit powerful interests. Attacking these societal problems requires the bearing of burdens of social change, burdens placed on powerful interests like the alcohol and tobacco industry, or making corporations more heedful of workplace safety. Market justice ignores these adverse societal conditions and entanglements.
Finally, and more broadly, social justice in health requires policies that correct the “machinery of social injustice” embedded in disparities in income, health, and social status.
In effect, I was arguing that the “public” in 'the public's health' means that if we are to have more health we must alter how our democratic republic oversees the marketplace and defends privacy and promotes a wider free speech.
More health in a democratic republic means a healthier body politic.
Many of the important agencies established in the Great Society were organized around the principles of social justice in health achieved by regulating powerful interests to protect health, safety and the environment. Despite four decades of challenge and disruption by conservative democracy, and despite many attempts to weaken or deemphasize the mission of these public health agencies, social justice in health has become the central clarion call for public health.
In fact, alcohol policy was likely one of the most persuasive foundations of epidemiological evidence for what became known as the population perspective, one celebrated in Geoffrey Rose’s article, “Sick Individuals and Sick Populations,” and especially in his book The Strategy of Preventive Medicine.
Still, despite all these findings, by attacking the machinery of injustice, remains an “alien ethic in a strange land.”
For a variety of reasons, social justice has always had a vigorous, even furious opposition. This in a way is strange, because one of the principal accomplishments of the Great Society Era was the establishment of “society” and its organization as the principal source of our most serious social problems.
That thesis has remained in dispute for decades and has been met with challenges from prominent philosophers like Robert Nozick to television commentators like Glenn Beck. Beck equates social justice with national socialism or fascism, even communism.
Yet there is widespread acceptance of the public of the premise that advancing the health of the environment or the health of the people will require living together in different ways.
The first line of opposition to social justice is that of political resentment. "Who do they think they are?" critics from the right argue. ‘They’ being intellectuals, liberals, the Washington establishment, and so forth. The second line of opposition will be to change the subject, to create a new and more urgent agenda that supersedes social justice.
The third line of opposition will be an attack on the legitimacy of social justice itself. The fourth line of opposition will be to weaken agencies and institutions dedicated to protecting the public health or social justice by assigning hostile leadership, by bottling up new initiatives, by defunding initiatives, and by the privatization of essential tasks.
Later in my career, I devoted almost a decade to the cause of universal health care and health care reform while serving part of that time as an official of the New York State Department of Health. I argued then, as I do now, that health care reform is a species of social justice in health.
From the very beginning, I have treated public health as an ethic that fits uncomfortably within the American democracy. This is not so much because our democracy "rejects" the public health perspective and ethic. It is rather that our democracy is "divided," meaning that its structures permit and even encourage an openness to new ideas and new ways of tackling social problems, while at the same time affording multiple checkpoints for undermining and sidelining these new ideas to make them less threatening to established arrangements
I have noted that public health as social justice is one of our neglected “second languages of community.” That health as an interest of society is not reducible to individual interests is well-established in our Constitutional tradition, although there has been a tendency for judges to lapse into individualistic justifications for limiting liberty to promote the common health. Advocacy for more health for this or that cause should remind us that among democracy’s first responsibilities is promoting and defending the health of the citizenry.
The opposition to social justice is many-faceted. There are attacks on epidemiological research that claim association is not causation. There are attacks on social justice as social engineering. There are attacks on advocacy for social justice as attacks on the America way of life, on traditional values, on our tradition of individualism and individual responsibility.