Public Health Reports  [Printer-friendly version]
December 1, 2002


[Rachel's introduction: "The cornerstones of the precautionary
principle -- transparency and inclusiveness of decision-making,
action in the face of uncertainty, and accountability -- are
fundamental, not only to the practice and science of public health,
but also to the success and maintenance of democracy." -- Judith
Kurland, Harvard School of Public Health]

[Judith Kurland is a member of the faculty of the Harvard School of
Public Health. Address correspondence to: Judith Kurland, 1272 Beacon
St., Brookline, MA 02446; e-mail

The cornerstones of the precautionary principle -- transparency and
inclusiveness of decision-making, action in the face of uncertainty,
and accountability -- are fundamental, not only to the practice and
science of public health, but also to the success and maintenance of

Both public health and democracy flourish when information is broadly
disseminated and understood, when principles, benefits, and costs are
publicly debated, when decision-making is shared by those affected by
the policies, and when public interest is seen as more valuable than
private gain. Both are diminished when information is withheld and
data twisted, when the terms of the argument predict its outcome, when
actions to protect and advance the health of the public are defeated
by small private interest groups, and when government gives equal
weight to corporate interests as to public well being. In the case of
the public health debate, the danger is increased with the deification
of a skewed view of science.

The precautionary principle, which says that action should be taken
when there is evidence that not to do so would cause harm, is being
used increasingly to shape policy in Europe and elsewhere. Decades --
sometimes centuries -- before the understanding of germs, bacteria,
viruses, infection, and immunology, leaders in public health improved
health by implementing policies that were later supported and
explained by an advanced understanding of basic science.

The precautionary principle is based in science, in the two branches
of science central to public health: epidemiology and bio-statistics.
It is no coincidence that so many contributors to this special topic
issue of Public Health Reports have cited the model and experience of
John Snow. The branch of science that he established has laid the
foundation for the greatest improvements in health in mankind's
history. Now, instead of developing policy to improve health and
protect the public based on these proven scientific methodologies,
proponents of an activist public health are fighting a rear-guard
action to protect the cornerstones of public health. Where opponents
of an activist public health agenda, which includes the implementation
of the precautionary principle, have succeeded is in having health
science narrowly defined in terms of laboratory science, physiology,
and biochemistry. This limited definition ignores the breakthroughs in
occupational safety, environmental science, maternal and childcare,
infection control, sanitation, and behavioral health that preceded the
advanced developments in bacteriology, immunology, and genetics.

This is not to denigrate the more recent sciences or curative methods;
it is to remind us that we have many tools, many means at our
disposal. From Hippocrates to John Grisom to Henry Bowditch,
leaders in public health and medicine admonished their followers and
the public to look at environments and behavior, to construct
healthier housing and schools, to have clean water and air, to think
more about prevention than about cure. We should use all methods that
discern patterns, cause and effect, and determinants of health. To
ignore the evidence of epidemiology and bio-statistics is to compound
error through inaction. And inaction in the face of preventable
disease is unacceptable.

Why are we at this apparent impasse and what can we do about it? We
must face several issues -- raised in these articles and elsewhere --
that appear to thwart the adoption of the precautionary principle for
public health. One is the misunderstanding about what is and what is
not science, and here public health must reclaim and reassert the
importance and worth of its basic sciences. But the other impediments
say as much about the beliefs of our society and the stage of our
democracy as they do about public health, and those battles must be
joined to others.

First is the issue of transparency, the information available to the
society as a whole, and the truth about the benefits of decisions to
act or to not act. There are many dilemmas here; often, the source of
facts and information are the very industries or interests who oppose
action. We have seen this with the tobacco, lead paint, petroleum,
pharmaceutical, and asbestos industries, whose control of information,
doctoring of studies, support for biased research, and suppression of
information have made it impossible for the public and independent
analysts to share in unbiased information. From the auto manufacturers
who, 40 years ago, knowingly and willfully produced cars that killed
to those manufacturers who, two years ago, utilized defective tires
that killed, the ability to withhold information is powerful. From
drug manufacturers who contract the right to suppress research studies
critical of their products to those who blatantly report false
findings, the ability to publish untruths and half-truths in peer-
reviewed journals is destructive of the public's capacity to make
informed judgments. But that control of information is exacerbated
when public bodies and the fourth estate abet the misinformation. The
dismissal, banishment, or even punishment of critics and whistle-
blowers within public agencies or government contractors makes it hard
for the public to gain access to dissenting views. When private
interests, such as the gun lobby, promote congressional bans on
gathering and publishing information, or when administrators "gag"
employees critical of pro-industry policies, it becomes virtually
impossible for the average citizen or even institutions to gather that
information themselves.

The lack of data and information is often an excuse for inaction in
the face of real harm. If one of the hallmarks of our democracy is
inclusiveness of decision-making, then the ability of a handful of
powerful interests to deny the existence of critical information, or
to hire apparently objective experts without revealing those
relationships, is destructive to the interests of both public health
and democracy. Inclusion also means the consideration and costs of a
full range of alternatives, which must also mean a full range of the
societal, long-term, and non-direct costs of inaction. In the face of
overriding evidence, not only of global warming, but also of the
health, environmental, and ecological costs of inaction, our society
still does close to nothing while opponents of action divert us with
both fantastic consequences of action, and self-serving and unique
theories on the nature of the universe. When three petrochemical
scientists, supported by the industry, are invited to appear before a
congressional committee to argue that global warming is a myth, and
the 300 leading, award-winning scientists urging our nation to take
strong, aggressive action on the issue are ignored, the entire notion
of transparency and inclusiveness is moot.

Action in the face of uncertainty -- a third element of the
precautionary principle -- is both its most vulnerable and
intellectually most important one. The other three may be morally more
important, but to admit that we do not have, and may never have, all
the evidence we would like is to engage in an intellectual quest that
underpins public health. To the modern observer, insisting that
doctors wash their hands between patients seems not just obvious, but
also benign. But without the "evidence" that was to come much later,
this request seemed to many baseless, and the opposition came from men
of science who wanted hard proof of cause and effect, not just an
accumulation of observation and relationships. Practice changed before
bacteriology would "prove" the reason for doing so, but the better our
laboratory and diagnostic science, the harder it seems to accept the
fact that we should act in the face of uncertainty. For example, the
relationship between air pollution and pulmonary disease seems so
clear to anyone working with communities subject to inordinate
pollution. But if we don't measure certain particulates, if we don't
yet see the physiological change, then lack of transparency and lack
of certainty can lead to inaction. However, if we take to heart the
requirement of doing no harm, also quoted widely in these articles, we
are moved to make the logical decision to act.

This brings us to the fourth cornerstone of the principle,
accountability. It is here that our society has the most to overcome.
Too much of our inaction in the past and the present is because we
have implicitly decided that some risks are easier for our society to
bear because they fall disproportionately on the poor, on workers, on
people of color, on our soldiers, and on the people of other
countries. Also, our inaction is because we have implicitly decided
that the costs are too much to bear when they fall on corporations,
the wealthy, and the politically powerful.

The articles in this issue, with case studies ranging from silica
and lead to tobacco and anthrax, from Agent Orange to the blood
supply, bear this out. For years, in the face of overwhelming evidence
from neutral sources, harmful products and practices were allowed to
continue while a great many people sickened and died. We need, as a
nation, to examine what it is that allows this to happen again and
again, but we also need to incorporate the elements of the
precautionary principle, whether or not we make it a national policy.

The courts in our nation are an important part of policy-making, but
to rely on them is to obviate our ability to make decisions in the
face of uncertainty. To rely on them is to relinquish responsibility
for including the public in the more meaningful way that is the basis
for democracy. If we had true transparency and inclusiveness in
decision-making, and true accountability and responsibility, we would
have the public understand the basis for decision-making and
participate in making decisions in the face of uncertainty. The series
of surgeon generals' reports on tobacco and smoking over the last four
decades is instructive. The evidence has been mounting for centuries
on the harm done by tobacco, but certainly by the first Surgeon
General's Report, it was overwhelming. Yet, other than increasingly
serious warnings on cigarette packages, restrictions on advertising
won through a lawsuit, and some restraint on sale to minors, not much
changed in 40 years. It took leaks of information, an incorruptible
whistle-blower, and indignant attorneys general from states whose
health care budgets were ballooning, to force a major change in
policy. As welcome as this was, it is a sorry and inefficient way to
make policy. And we must admit the changes in the tobacco industry are
not half of what could and should have been made if the health of the
nation were the guiding principle in decision-making.

Instead, as one of this issue's authors so clearly states, our
guiding principles are very different: industry has the right to
produce what it will; products are assumed safe until proven otherwise
under a system that makes it almost impossible to prove; private
profit is more of a right than the right of society as a whole to have
healthy conditions; and public health is a narrow interest while
private industry represents a broader public good.

These are dangerous principles -- dangerous to our health and
dangerous to our society. It is not a sin, nor is it surprising, that
private industry puts profits before health; it should not shock us
that they go to extraordinary lengths to protect their ability to
manufacture and sell, unfettered by any interference by government. We
have been shocked when they have lied, cheated, and broken the law; we
have been surprised when they have shown a total disregard for life or
health, but we would be naive to think that their interests lie with
society's as a whole. The recent outrage at corporate greed has not
been because they put profits before people; it has been because they
did not obey even the rules of corporate finance and reporting. To
correct the latter will not address the former. It is the role of
public health and of government to seek and protect the greater good.
That is at the heart of the precautionary principle, and at the center
of our democracy.

Copyright 2002 Association of Schools of Public Health