Healthy People 2010: objectives for the United States
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7238.818 (Published 25 March 2000) Cite this as: BMJ 2000;320:818All rapid responses
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Davis' editorial correctly observes that the Healthy People 2010 tobacco-related goals are "virtually unattainable" as "smoking prevalence is unlikely to fall by a percentage point a year from 1997 to 2010 given that it has not declined at all since 1997 and during the previous 25 years it decreased by only half a percentage point a year."1
The Healthy People 2010 targets related to cigarette effects will continue to be unattainable as long as the health agenda is the product of an unmentionable, the tobacco taboo preventing even saying the word "prohibition" as a solution. So that simple most direct solution method remains unrecommended and unused.
Instead, we are limited to indirect and near-unmangeable methods, for the distant future, the ineffectiveness of which is obvious by the continued death toll. This leads to yet additional numbers of proposals, proposals whose unmanageability, number, flaws and inadequacies are rightly being pointed out.
Let us remember the pre-1861 lesson from U.S. experience with slavery. "To preach distant reform is very cheap philanthropy—the cheaper in proportion to the distance. The feeling of self-satisfaction exists without the necessity of personal sacrifice."2
Let us see what types of actions are available when direct and immediate solutions are not feared to be recommended and taken, not ruled out as a priori unmentionables. For example, we can note Iowa's 1897 approach: ban manufacture, sale, exchange, and disposition of cigarettes and cigarette paper.3
Another direct approach is the 1909 Michigan law: a ban on manufacture, sale and give away of cigarettes with any deleterious ingredient or adulterant, meaning all cigarettes.4
These direct approaches are civil law institutionalizations of the already existing common law "right to fresh and pure air" derived from British court precedents as applied in U.S. case law.5 One direct approach is simply to enforce that already long existing common law right.
When deaths foreseeably result as natural and probable consequences of actor intent, here, cigarettes containing foreseeably fatal ingredients, another direct approach is criminal prosecutions, pursuant to the "universal malice" criminal law concept.6
Such direct actions are not being recommended. Instead, there is a focus on indirect methods, the ineffectiveness of which is obvious by the continued death toll leading to yet additional proposals, proposals whose flaws and inadequacies are rightly being detailed. Let us urge responsible officials to cease to fear the word "prohibition." Let us urge direct actions, bans and prosecutions pursuant to the vast body of law and case law developed by experience over centuries. Instead of a ten year delay until 2010, let us have Healthy People 2000.
1. Davis, RM. "Editorial: Healthy People 2010: objectives for the United States." BMJ 2000;320:818-819
2.(Julius Pringle, quoted in Dwight L. Dumond, Anti-slavery Origins of the Civil War in the United States (Ann Arbor: Univ of Michigan Press, 1939), p 51.
3.Section 5006, 1897 Laws of Iowa
5.Rex v White and Ward, 1 Burr 333 (KB, 1757), etc.
6.Mitchell v State, 60 Ala 26 (1877), etc.
Competing interests: No competing interests
Healthy People 2010: objectives for the United States
Dear Editor - Of the 28 "focus areas" selected by the United States
Department of Health it seems fortunate that alphabetising highlights the
one with possibly the greatest significance1 - "access to quality health
services". The Healthy People 2010 website2 is candid in its admission
that the proportion of under 65's without health insurance has not altered
in the past decade. It also confirms that 44 million Americans have no
health insurance.
How can such deficiencies be remedied with sufficient rapidity to reach
the 2010 goal of 100% having health insurance? Given a truly national and
accessible service the other 27 goals would seem reasonable if rather
numerous. However, there remain two difficulties. Firstly, the
significant number who have neither health insurance nor qualify for
Medicare/Medicaid. Secondly, the spectacular waste of resources for those
fortunate enough to have health insurance. I was startled last year when
discussing standards of care with a group of interns and residents in
internal medicine in New England. The commonest reason for ordering an
investigation was "CYA" or "cover you ass" (sic).
Until the U.S. has healthcare for all and a significant reduction in
defensive practice it is difficult to see how national goals are
appropriate let alone attainable.
Adrian R Brown
specialist registrar in forensic psychiatry
Wathwood Hospital, Gypsy Green Lane, Wath-Upon-Dearne, Rotherham, South
Yorkshire S63 7TQ
1 Davis RM. Healthy people 2010: objectives for the United States.
BMJ 2000; 320: 818-8.
2 US Department of Health and Human Services. Healthy people 2010.
Washington, DC: US Department of Health and Human Services, January 2000.
www.health.gov/healthypeople/
Competing interests: No competing interests