I may as well repost this here. I didn't realize back in 1996 when I wrote it that things would get this bad this quickly:
Implementing Health Policy: Means and Ends
The problem
Scientific investigation into the relationship of nutrition to health and disease has produced an immense body of data. Given the nature of science, the results of any one study must be understood within its narrowly defined context. Accordingly, a broad view of the relation of nutrition to health and disease is accurate to the extent that one understands those narrowly defined contexts and not by any superficial similarity or dissimilarity between test results centering around any particular theme—i.e., coffee and coronary heart disease, or herpes and arterial plaque.
It’s been said that the general public lacks the knowledge, ability, and experience necessary for an accurate overview of this topic. Of course, by definition “the general public” is the necessarily large group of people formed when selecting for any narrowly defined level of knowledge or expertise. Everybody is a part of someone else’s general public.
Still, the problem exists of how to get the knowledge out from where it is being generated to a more general level in such a way as to make the greatest positive impact on people’s health.
The ethical considerations
It’s at this point that ethical questions must be raised. To paraphrase Lenin, who is to decide who does what to whom, for what reasons, and for what ends?
At times it appears the temptation is to think that if it’s left up to others to make choices about their health, they won’t make the right ones; and because the experts' or policy makers' knowledge is so valuable, or of such potential benefit, or the situation is so critical, the decision must be made for them.
For one reason or another, this mindset is oblivious to the fact that a fact (the descriptive) cannot lead directly to a command (the imperative). It is always mediated through the idea of what one ought to do (the prescriptive).
1 Such an idea is the product of individual judgment.
The difference between a society existing in a state of liberty or in what, throughout most of history, appears to be its default mode is persuasion of the individual judgment by knowledge and example (accomplished in the context of limited proscriptive law) vs. coercion of individual will by force or by its threatened use (from “Your money or your life”--the Highwayman to “The American people are going to get a health care bill whether they want one or not”--Senator Rockefeller).
The public policy implications
We must look at the specific topic of effecting public health in the general context of social structure. What type of society do we have and what type of actions are appropriate to it? And for those involved in international efforts, what is the type of society in which we will work and what are the special constraints it places upon our actions within it? For instance, if the opportunity to care for the health of a people living under a repressive regime comes only by working through the official channels of that regime, do we accept the opportunity and do all we are permitted, though it may fall short of all we are capable of doing?
In either case, the political constraints upon and consequences of such actions are built directly upon the answers to these questions: What is the end to which we want to apply scientifically gained knowledge of nutrition and health? That answered, what are the means we will employ?
In the broadest terms, is the end to be a state of knowledge in which the individual is able to understand the possible consequences of his behavior and is then free to choose according to his own desires and goals, the general state of society then an amalgam of informed individual choices? Or is the end to be a state of being in which the individual’s choices are limited by others to a range calculated by them most likely to result in that state of being, the general state of society then an expression of coerced individual actions?
The latter end is characteristic of family (both nuclear and extended), of tribalism (the mythologized extended family), of socialism (re-mythologized tribalism in a suit), and of totalitarianism (demythologized socialism with guns). All consist in the individual being forced by others using various means into behavior that will be
1) for his own good later in life (the family),
2) for society’s good (tribalism/socialism), or
3) for the good of the individuals in control of the society (totalitarianism).
While this is universally seen as appropriate within the child/family relationship for developmental reasons, its application to society at large by some group within that society, or by one society to another, has been the cause of most social ferment throughout history.
The track record of authoritarianism has been excellent in terms of its persistence throughout history and across cultures but has been abysmal in terms of knowledge (Galileo and the Catholic Church, Lysenko and Soviet genetics, German anthropology and the Nazi state), in terms of human rights (the Inquisition, the Holocaust and other pogroms, China and family planning, most post-colonial African dictatorships) and in terms of technological inventiveness (the miserable record of Soviet-style five year plans, Mao’s fixation on steel production and its disruption of the flow of goods and services, the extreme environmental damage left behind in the former Eastern bloc as a direct result of centralized control of capital, labor, and resources).
The reason for this is that authoritarianism or statism doesn’t allow the freedom for the wide range of viewpoints necessary for generating and testing hypotheses, let alone the ad hoc experimentation and innovation by individuals for their own reasons that form the basis of a developing, knowledge-based, technological society.
2 Discovery is not allowed to take one where it will--it must be restricted to the party line (witness the vitiating of the ideal of the university by notions of political correctness).
Given the complexity of life, the narrow range of understanding possessed by any particular group is guaranteed to fall short at some point. Given the concentration of power exercised under a centralized system, the failures are guaranteed to have widespread and crippling effects. By contrast, the multiplicity of successes and failures over a wide range of scale that appear so chaotic in a state of liberty have the benefit of limiting the damage and of spreading throughout society successes which can be emulated and modified to fit local conditions.
3
Among some, the attitude seems to be “We know so much now, but people don’t care or won’t listen or aren’t changing fast enough. What can we do to change things now?" The yearning appears to be for some universal remedy. This may be “nice”, but is hardly practicable, let alone even conceivable. It would require an understanding of life and society beyond the capability of any individual or group. Universalist approaches in the realm of economics and government have proved uniformly disastrous.
So what can be done?
4 Using available resources and even contributing their own, those of like mind should join together to form organizations for the purpose of getting out their message about nutrition and health. This is nothing new. Most of the greatest advances in science, education, medicine, and social welfare came about in just this way.
5
Independent organizations have the flexibility to tailor their message and target it to those they know best and to adjust the message as conditions warrant. Independent organizations also assume social responsibility by recognizing that, when all is said and done, somebody is going to have to do the work--it won’t get done just because it ought to be done or is worthy of being done.
"But, somebody ought to pay me to do it because I'm right!"
Some health professionals seem to believe that the government should sponsor their efforts to counter the self-interested efforts of others (nutrition and diet quacks for example) because they are right and the others are wrong, because they are altruistic and the others are not. It may be true that they are factually correct and genuinely altruistic, and that what they wish to do will have a beneficial effect on many people, but it doesn’t follow necessarily that the government should fund them.
This is a manifestation of a widespread phenomenon brought about by the advent of the secularized state. Instead of viewing the state as a limited means to a limited end, the tendency has been to imbue it, a temporal entity, with the attributes of a transcendent final judgment in which all injustices and inequalities are finally rectified. In this way, the secular state has been categorically, though not personally, deified and expected to act accordingly (something of a diffuse divine right of kings).
This is seen in those who believe the necessary response to a social ill is the passage of a law, especially a federal law, and the enactment of a program, especially one that they can devise and administrate (and that not necessarily for cynical reasons). Those who feel they are on the side of right, certain they aren’t acting against society’s interest, often appeal to the State to aid them in their struggle against evil. Since the πνευμα of the secular state is money and power, they ask to be endowed accordingly. It’s pathetically naive and dangerous.
Power accumulates power. Government grows until it meets a limit, either a systemic one (Constitutional limits), or a fiscal one (limits imposed by the amount of money it is able to generate or extort from its own citizens or those outside), or a social one (limits provided by massive societal non-compliance or armed insurrection or by other countries’ response to aggression or perceived weakness). Even then it still has great power to drain resources and people from productive enterprise and turn them to its own ends. In this way it is functioning as a parasite living off the body politic.
6
The question should not be the degree of insult the victim is able to take without expiring. It should be how free of the parasite he can be and still get any survival advantages it may convey. He needs to ask constantly what those advantages are and to question what the State and its advocates claim them to be. The danger comes from his turning over to it the control of larger and larger areas of his life, believing that he will then be free from insecurity, pain, and poverty.
7 It is a misplaced trust.
Many, if not most, of the modern state’s most intrusive and manipulative ventures (Social Security, the EEOC, the EPA, and OSHA, to name a few) have come into existence by someone promising that they were only trying to help society.
8 In this way regulatory agencies prosper and extend their spheres of influence in ever more self-aggrandizing roles of protectors of society, yet limiting the ability of society to respond to its own changing conditions.
The global/historical approach
The state of global nutrition may be bad in many areas (as bad as it used to be nearly everywhere), but it’s still far better than it used to be. Over the past three hundred years there have been tremendous successes in nutrition. From a time when the average weight of an adult French male was 110 pounds and many were idle because they were just too weak to work or even wander much,
9 when the productivity of fourteen hour days was small in comparison to today’s per capita productivity (machines notwithstanding) because the people just did not have enough energy,
10 when the adult onset of degenerative intestinal and other diseases as a result of poor pre- and perinatal nutrition dwarfed anything today in the same Western countries,
11 we have arrived at a time when many health problems arise not from a lack but from an abundance of nutritious food.
A lot of this has come not through knowledge of what is, on the margin, more or less healthy to eat, but because technology has made more food available to be eaten by more people. Of course, some would not see this as an advance in nutrition because it was not the result of consciously planned and rationally thought-out endeavors implemented through the state sector, a classic example of the cart before the horse.
A more in-depth study of the horse is called for rather than more grandiose plans of what to load onto its back.
Notes
1. See
The Abolition of Man, C.S. Lewis.
2. In
The Spirit of Democratic Capitalism, Michael Novak observes that most of the technological innovations that have shaped modern society have been produced in the West, in non-authoritarian societies (i.e., Protestant or Reform history—though Geneva under Calvin was about as authoritarian as anything under Rome). A similar culture-shaping change was manifested in the eleventh century from the classical Roman or Greek view toward physical labor and the employment of mechanical labor saving devices to that of the medieval church: God labored and formed man and the world and called the work of his hands good; in working, man emulated his creator. The monks studied and worked the land with their own hands. They believed they worshipped God in both activities. The new view of the dignity of physical labor adopted by the educated, the acceptability of business, and the usefulness of labor-saving devices lay the groundwork for the experimentation of modern science (vs. the intuitive mode of classical science), the existence of a personal and societal life created and maintained outside the authority of the ancients (whether religious or scholastic), and the modern technological society. (See "God and Technology", Discover, 1981)
3. It was precisely because of these considerations that the structure of the United States federal government was engineered--a union of states, not their assimilation into a single state; a division of the federal government into separate branches of power, each independent yet not self-sufficient; a limited set of directives embodied in the Constitution and Bill of Rights for the purpose of guarding the union of the various states, those states and their individual citizens being free to carry out the social experiment as they will, the general nature of the federal law being limited and proscriptive rather than all-encompassing and prescriptive.
The analogy to a multi-celled organism is interesting. Division into tissues, organs, and systems (both organismal as well as redundant and complementary metabolic pathways) gives the multi-celled organism an individual resistance to environmental conditions not available to the single-celled organism. Although form and structure impose limits on range or type of movement, they are proscriptive, not prescriptive--they don’t dictate individual movements or actions within the range inherently possible.
4. One answer, as seen in the formation, deliberation, and recommendations of Hillary Clinton’s Health Task Force, seems to be to act secretly, swiftly, unilaterally, idiosyncratically, and paternalistically to formulate the fix, and then attempt to sell it to the general populace by appealing to their fear and their greed, by exploiting class envy, and fomenting distrust of existing institutions (i.e. the medical establishment and the pharmaceutical industry). This is exactly the tactic used in the scams of phony nutritionists.
“We are a national resource of nutrition scientists which the promoters of questionable nutrition have convinced the public does not exist by fraudulently representing that “doctors don’t know any nutrition, so listen to us.” We are seeing the mass marketing of misinformation.”
--Victor Herbert, M.D., J.D., “Will questionable nutrition overwhelm nutrition science?” in The American Journal of Clinical Nutrition 34: December, 1981, pp2848-2853.
Such an approach is inconsistent with the nature of a free society.
5.
The Americans: the National Experience, Daniel J. Boorstin.
6.
People and Plagues, William H. MacNeill.
7. See
The Road to Serfdom, F. A. Hayek.
8. Dirigist centralized government seems to have been a worldwide phenomenon during the first half of the 20th century. Its legacy in human suffering is unmatched in history. Of course, it didn’t just happen. People with certain world-views labored intensely to bring into being a world defined by their ideas of what constitutes man’s nature. It’s instructive to note both the means they used to do it and the ends they used to justify them. See
Modern Times: a History of the 20’s to the 80’s by Paul Johnson.
9. See Robert W. Fogel's 1993 Nobel Prize Lecture,
Economic Growth, Population Theory, and Physiology: The Bearing of Long-Term Processes on the Making of Economic Policy.
10.
ibid
11.
ibid