The Public Health Leviathan

As our public health officials endeavor to remake the Bill Murray classic Groundhog Day when it comes to mask mandates and over-reliance on the precautionary principle over prudence, it might be useful to consider how the entire notion of health regulation started in the United States. Clayton Coppin and Jack High’s sadly overlooked history of the evolution of the FDA, The Politics of Purity, is an eye-opening account of how the partially well-intentioned and fully ambitious Harvey Washington Wiley founded and rapidly expanded the regulation of food and drug purity at the federal level in the United States. Today it would be bordering on lunacy for anyone to question the government’s pervasive role in monitoring and regulating what we eat, what medicines we take, and how those medicines are developed, tested, and manufactured. But in the early 20th century, the federal government played little or no role in this field until a political entrepreneur started us along the path to giving scientists and public health officials a prominent and increasingly powerful role in the lives of everyday people.

H.W. Wiley was a chemist by training and held a position at Purdue University. And it might surprise people to know that the person most responsible for the founding, development, and expansion of the government’s oversight of foods and drugs was in fact an advocate for sugar consumption, particularly among children. He believed that sugar was a critical part of every person’s diet. He once said that “[c]hildhood without candy would be Heaven without harps.” The person who founded the FDA, the organization that now has control over virtually every aspect of food and medicine safety thought we should be popping M&M’s and chugging Dr. Peppers all day.

Science of course has evolved beyond the view that sugar should play a central role in the diets of most people, just as we no longer believe that miasma theories help us understand the spread of infectious diseases. A reasonable person might very well argue that no matter what the founder of the FDA believed, the important thing is that public health officials today are up to date on the scientific consensus and look out for citizens by applying that knowledge to the health challenges facing the nation.

However, as public choice research reminds us, these same public health officials operate in a bureaucratic framework and are neither omniscient nor benevolent. Nor are they being asked to weigh tradeoffs and relative risk. Those who have spent their careers focusing on infectious diseases will likely focus exclusively on ameliorating those diseases. And our recent experience would suggest that it is naïve to hope that public servants will consider and understand alternatives, trade-offs, and relative costs and benefits.

The Bureaucrat’s Point of View

Furthermore, it is not merely well-intentioned altruism that explains the origins of the government institutions that have exerted stunning dominance over the social and economic aspects of our daily lives during the past 16 months. No matter the relative competence of the experts in their fields and their intentions, they are also people. They have desires and preferences. They operate within frameworks in their jobs and careers. Their actions can never be separated from where they are and the arenas in which they operate.

Entrepreneurs in markets see gaps in what the market provides and step in to start a new business and fill that gap. Gordon Tullock effectively extended that model to bureaucracies, pointing out that politicians and public officials are rewarded for saying “we need a new agency” or “we need more power over policy to protect citizens” and perhaps most importantly, “I’m an expert—I know what’s best for you.” Just like private-sector actors, bureaucrats are ambitious, energetic, dedicated to their jobs, and therefore wish to expand their budgets and power.

Tullock argued that we must analyze public officials as essentially self-interested actors, even though they believe they are acting in the name of the “public good.” Economists believe people wish to maximize their utility within the set of institutional constraints they face in the market. A person may not necessarily prefer to be materially better off, but no matter their preferences, they seek to maximize them. For Tullock, public officials are no different. Their preferences might be described, or perhaps represented, as being public spirited, but that doesn’t change their fallible nature or their focus on maximizing their personal goals and utility. They see themselves as promoting the public’s health, but in many cases, their preferred policies will remove or shape your choices in living according to your preferences.

We have to acknowledge that the history of American public health can point to success stories and catastrophic failures.

The key difference is that in markets, individuals have choices. When I buy food, I can purchase it from several different companies. I am voluntarily entering into a contract with a service or goods provider, and if I don’t get satisfaction in that exchange, I can choose another provider the next time around. I make that choice based on the available information from the seller, but also from friends, family, or my own research and preferences. Sellers cannot coerce me, but they can convince me to purchase their products and maintain that relationship through continued quality assurance and consistency.

With the government, I often have no such choice. The government doesn’t convince me with solid evidence, it forces me to follow the rules it sets out. I currently cannot choose to be regulated by another FDA or advised by another CDC. The state has monopolistic power over the things it regulates. When individuals claim to be acting in my best interest, I have to consider their decision-making calculus. We have to examine the underlying motivations and incentives of public officials just as we would someone trying to sell us a car. However, we usually don’t have the choice we do in markets, and frequently government officials do not act in ways that actually promote the public interest.

Taken this way, the current explosive growth in government authority in the arena of public health has to be viewed as just one part of a continually growing and expanding role of the state in virtually all health-related aspects of our lives. From the early establishment of the FDA, we might look favorably upon attempts to regulate meat packing and transportation as a sign of progress in providing Americans with safer food. But we also should know that local butchers lobbied for regulation of large meat processors to limit their competition. We would have to acknowledge that the history of American public health can point to success stories and catastrophic failures such as the Tuskegee syphilis experiments—a horrible violation of the rights and dignity of African Americans.

More recently we have seen government officials tackling other issues that might seem to provide more unequivocal utility. Take for example the work that many public officials did to slowly constrict the use of tobacco among Americans. In particular, consider the legal and regulatory actions governments have taken against tobacco companies, perhaps most notably the limits Mayor Michael Bloomberg imposed on the consumption of tobacco in New York City. These laws violated the freedoms that some smokers enjoyed, but they undoubtedly saved lives and limited the negative externalities associated with secondhand cigarette smoke. We might look at seat belt laws and child seats and cars and reach similar conclusions.

But the record shows a number of notable failures. Soft drink regulation was of course also the brainchild of Bloomberg in New York City and here we have perhaps the best example of how a broad vision of the public good animated by ambitious public officials and politicians can abruptly go from helpful to intrusive and misguided within a short period of time. We can add in various initiatives from the national government, such as the infamous food pyramid that directed Americans to consume a diet based more on the political interests of dairy and grain farmers rather than what was healthy. Public health officials were also behind the “War on Fat,” which incentivized Americans to eat many more carbohydrates and fewer proteins and fats. At the time, science was behind his theory, but the unintended consequences of this policy appear to have included the massive increase in Type 2 diabetes as well as ballooning obesity in the US.

Our Covid Experts

This brings us to the past 15 months and the current dictatorship of the CDC and FDA over Covid policy, testing, and vaccines. The government’s record on these policies is decidedly mixed. Covid tests remain expensive, overly regulated, and still very difficult to obtain. Home testing in many other countries is widely available and has given policymakers in those countries more weapons to battle the virus. While the US has done comparatively better in vaccine distribution, the FDA still delayed the deployment of the various vaccines for months longer than might have been necessary because of bureaucratic regulations and overly cautious concerns about side effects. Rather than simply providing individuals with information about the relative risks and benefits of vaccines, and providing immediate access, the government was paternalistic and slow-moving.

And while the vaccine rollout and the recent approval of a new Alzheimer’s drug might lead to a more optimistic long term view of public health, the CDC’s decision to now recommend the return of mask-wearing even among vaccinated Americans because of the possible risks to the unvaccinated perfectly shows how a myopic focus on disease management cannot take the place of public policymaking that balances goods. It is basing these decisions on information that should be assessed by individuals to fit their risk profiles. Instead, the agency acts as if it knows best, rather than the citizens it supposedly serves.

The return of the mask echoes the earlier, very costly failure of the public health Leviathan in pausing the Johnson & Johnson vaccine rather than allowing individuals to make their own choices based on the evidence. This decision began the process of undermining public confidence in the vaccine and led to a sharp decline in vaccination rates and public trust in the process. The US was perhaps a month away from legitimate freedom from Covid when a highly questionable decision by the CDC put an intense public spotlight on six unfortunate cases of blood clots among millions of individuals who received the vaccine with no reasonable scientific justification.

What is clear is that the expansive reach and power of the health Leviathan is here to stay. Mask-wearing is going to be a conspicuous part of American life for months if not years to come. Dr. Fauci and whoever succeeds him will continue to hold significant sway in the public arena. And the recent pivot to argue that racism is now a public health issue will ensure that health officials will continue to expand the scope of their input into the daily lives of everyone.

H. W. Wiley would undoubtedly be proud of the expansive and intrusive bureaucratic apparatus that he planted and nurtured. It has managed to force its way into the lives of almost everyone today and not always to the benefit of most citizens. Now a potentially permanent pandemic has allowed his creation to establish itself at or near the top of the bureaucratic food chain. It’s just too bad that it doesn’t advocate as much sugar as Wiley used to desire. A spoonful of sugar might help this medicine go down a bit more easily.