Over the years, the field of public health has transformed in accordance with scientific knowledge and population needs. During the 19th century, because scientific knowledge of disease etiology was scarce, public health was only able to protect populations from potential sources of ill-health through general health guidelines which educated the public on the role of moral degradation and miasma in producing infectious disease (Colgrove, 2018a). Since that time, information on disease risks has grown immensely, causing an epidemiologic transition.
Beyond preventing the spread of infection through scientifically supported interventions, practitioners today are also tasked with preventing non-communicable diseases by ensuring populations have access to resources despite their socioeconomic status, race, or gender (Colgrove, 2018e). In the United States, public health workers must contend with forces such as capitalism and poverty, which produce ill-health among marginalized populations. Two examples of these forces’ negative effects are the popularity of cigarettes—and subsequent increased tobacco use—and occupational hazards brought about by the Industrial Revolution and perpetuated under capitalism.
In examining the historical and ethical implications of tobacco use and occupational illness on the health of marginalized populations, it is evident that, in order to improve health outcomes and protect those most vulnerable, a paternalistic approach must be adopted to limit the rights of corporations, thereby strengthening the ability of public health officials to develop effective policies and interventions.
In order to understand the negative impacts of unregulated and unsafe working conditions on the health of workers during the Industrial Revolution, it is first important to analyze the historical and social conditions which allowed occupational hazards to exist. Throughout the 19th century, the construction of American society began to shift as people migrated from the countryside into burgeoning cities in search of job prospects. During this time, thousands of immigrants also arrived in the United States and settled in the newly formed cities, causing a 40% increase in population (Colgrove, 2018c).
Despite the high levels of disease and mortality associated with urban life, the emergence of factories and other innovations of the Industrial Revolution provided job prospects for people in need of work. The Industrial Revolution provided jobs, which exposed workers to more occupational hazards. According to Rosner, “along with increased production came a rapid decline in working conditions for many laborers…exposure to chemical toxins and metallic, mineral, and organic dusts; and unprotected machinery made the American workplace among the most dangerous in the world” (2000, pg. 536). Furthermore, because regulations had yet to be put in place, people often worked 100 hours per week in an effort to support their families (Colgrove, 2018d).
Common jobs during this time included gun foundries, slaughterhouses, and factories, all of which exposed workers to occupational hazards like poor ventilation and accidents. One of the most important cases in understanding the exposure of vulnerable populations to occupational hazards and the need for paternalistic measures to limit the rights of employers and corporations is the fire at the Triangle Shirtwaist Factory. The Triangle Shirtwaist Factory, located in New York City, employed over 600 women—many of whom were immigrants—in the creation of corsets and shirtwaists (Rosner, 2000, pg. 537). In 1911, the factory was engulfed in flames and, because exit doors were locked from the outside by the factory owner to prevent theft, the women were unable to escape and died.
The deaths at the Triangle Shirtwaist Factory caused an uproar and, ultimately, the tragedy was responsible for the establishment of regulatory policies on corporations (Rosner, 2000, pg. 537). These regulatory and protective policies were instrumental in challenging the common misconception at the time that “the worker both controlled and was responsible for the conditions of his or her work and that the employee…assumed the risks of employment and therefore responsibility for occupational injury or death” (Rosner, 2000, pg. 538). This mindset, known as the “façade of choice,” assumes that workers have the agency and financial ability to find a safer job should they deem it necessary but, in so doing, ignores the coercive role socioeconomic status and racism play in controlling the outcome of workers’ lives (Bayer, 2018b).
Occupational hazard remains a significant threat to the health of modern day workers, highlighting the need for increased regulation of corporations at the federal level. Under a capitalist system, corporations and employers are often given the same rights as individuals, which can result in human rights violations in the workplace. With an understanding of the history of the Industrial Revolution in the US and its role in producing ill-health among low SES, oftentimes immigrant workers, it is clear that public health officials must adopt a paternalistic approach in limiting the rights of corporations in order to protect the health of workers.
Additionally, because modern occupational illness is associated with long-term exposures that do not produce immediate effects on health, public health officials must collaborate with scientists to solidify the link between ill-health and various occupational hazards. Beyond the inclusion of scientists, collaboration between public health and government is also necessary, as the government has a “responsibility, grounded in its police powers, to protect the public’s health and welfare, because it alone can undertake certain interventions, such as regulation, taxation, and the expenditure of public funds” (Childress et al., 2002, pg. 170).
However, as discussed by Childress et al., “it is not sufficient to show that social-cultural factors influence an individual’s actions,” but rather paternalistic public health interventions are only justified when it can be proven that such factors compromise an individual’s agency and autonomy (2002, pg. 176).
If they are to improve the health of vulnerable populations and maintain the public’s trust in the field, public health officials must also create an open dialogue with target populations of paternalistic interventions. Another example of the negative effects associated with lack of regulation of corporations can be seen in the rise of tobacco use in the US. Beginning in the 1900s, advertisements which glamorized cigarettes and promoted addiction emerged in the public sphere. As a result of these campaigns, the rate of cigarette smoking increased exponentially; by the early 1960s, it was estimated that 4,000 cigarettes were smoked per person, per year (Colgrove, 2018e).
Smoking was extremely normative at the time—50% of men and 30% of women reported using cigarettes. However, the rate of smoking sharply declined in 1964 following the Surgeon General’s Landmark Report linking smoking with lung cancer. In response to the decline in sales, tobacco companies launched a new wave of advertisements which aimed to minimize the scientific discovery reported by the Surgeon General (Colgrove, 2018e). Despite the confirmed negative health outcomes of smoking, tobacco companies prioritized making a profit over the health of consumers and “deployed their resources to influence, delay, and disrupt normative scientific processes” (Brandt, 2007, pg. 153).
Because tobacco companies are driven by maximizing profit and not health, it is necessary for public health to step in and impose regulations to protect individuals. Similarly to the case of occupational illness where workers do not have agency over their working conditions, tobacco consumers often do not have the ability to make an autonomous choice in regards to smoking. Not only are cigarettes highly addictive, but cigarette advertisement campaigns employ marketing strategies and deceit to trick consumers into smoking.
Following the discovery that smoking was linked to cancer, tobacco companies shifted their marketing techniques in order to maintain high profits and manipulated “consumers’ anxieties, promising social success and physical wellness from consumption of the product while threatening failure and discontent if it was not chosen and consumed” (Pennock, 2002, pg. 167-168). According to Goodin “there is something deeply offensive—morally, and perhaps legally as well—about the ‘intentional exploitation of a man’s known weaknesses’ in these ways” (1985, pg. 21). Faced with manipulative and immoral marketing techniques, consumers are stripped of their agency.
Thus, it is necessary for public health officials to implement paternalistic regulations on tobacco companies, such as requiring the dangers of smoking to be listed on boxes, taxing cigarettes, and limiting the amount of advertising space companies are able to use. The use of paternalistic measures in limiting freedom of tobacco companies is further justified when one considers the negative impact of smoking on others. Secondhand smoke and healthcare costs associated with cancer prove to be detrimental to the health of non-smokers. Because public health has a duty to promote the greatest good for the greatest number of people, action is necessary to prevent harm (Bayer, 2018a).
With a more in-depth understanding of the history of tobacco companies in the US and the ethical implications of advertisements, public health officials will be better equipped to design policies and interventions which are effective at protecting vulnerable communities. The history surrounding tobacco use and occupational illness brings to light many common ethical dilemmas faced by public health workers, one of which is the need to protect individuals from profit-driven corporations or employers, while still upholding the individual rights of consumers and workers.
Opponents of paternalistic interventions argue that adoption of such measures denies individuals autonomy to make decisions for themselves. Additionally, it can be argued that paternalistic measures are not effective because they require collaboration among multiple sectors—like public health, science, and the government—which do not always act perfectly. Finally, according to Mill, “the only purpose for which power can be rightfully exercised over any member of civilized community, against his will, is to prevent harm from others” (Nuffield Council on Bioethics, 2007, pg. 16).
While concerns about paternalism are valid, when individual human rights are violated by corporations, regulatory measures are needed to protect vulnerable people. Under capitalism, generation of wealth is valued higher than the health of workers and consumers. When corporations cause harm to communities, the government has an obligation to intervene and limit their rights (Colgrove, 2018b). Additionally “Mill makes it clear that his defense of individual liberty is founded on his commitment to advancing ‘utility,’ which can be understood as general welfare. Hence his principle is to be interpreted to allow the state to support “joint work necessary to the interest of society,” including, for example, regulations that limit working hours” (Nuffield Council on Bioethics, 2007, pg. 17).
Public health regulatory policies and interventions, influenced by history and ethics, are enforced in the interest of society as a whole. Analysis of the public health problems of tobacco use and occupational illness through the lenses of history and ethics provides insight into the conditions which permit ill-health among certain populations and offers a possible solution in the form of paternalistic policy and regulation. As seen in the history of occupational illness in the US, when corporations and employers have unbridled freedom, the health of workers is often compromised in the name of profit. Similarly, the tobacco industry manipulated the public using marketing tactics in order to maintain high cigarette sales, despite growing concern of the correlation between smoking and cancer.
In both of these instances, corporations and employers were able to take advantage of vulnerable populations due to the market freedom afforded to them in a capitalist society. When faced with forces such as these, public health officials cannot stand idly by and allow harm to come to populations. Through the use of paternalistic regulations of corporations and employers, public health workers will be better able to mitigate harm and contribute to the creation of a healthy and just society.