“Public health” is a multidisciplinary field that strives to improve human health through population-based interventions, including medical practices like vaccination campaigns and quarantines, disaster relief, occupational health, food regulation, concerns about bioterrorism and beyond (Mowat & Butler-Jones, 2007). Despite their many gains, public health programs also have a history of cooperating with or even spearheading eugenic policies in an attempt to improve population health.

Public Health in Canada and the USA
The field of public health includes medical doctors, nurses, epidemiologists, behavioral and social scientists, ethicists, engineers, veterinarians, laboratory scientists trained in a range of specializations, as well as those who have been trained in public health, often through graduate training. In contrast to individualized healthcare, public health focuses on population-level interventions and prevention rather than treatment.

The Public Health Agency of Canada’s mission includes improved health, the prevention and management of both chronic and infectious diseases, emergency response and preparation, as well as disseminating and gathering expertise globally and collaborating for improved public health policy (Government of Canada, 2004). In the United States, the Commissioned Corps of the Public Health Service work for more than 20 federal agencies, ranging from the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration, the Indian Health Service, the National Institutes of Health, Centers for Medicare and Medicaid Services, the Environmental Protection Agency, the Federal Bureau of Prisons, the National Park Service, the Departments of Agriculture, Defense, Homeland Security, and many others (U.S. Department of Health and Human Services, 2011).

A Brief History of Public Health
The history of public health can be traced as far back as 1500 BCE to the hygiene and health codes established in Leviticus and The Code of Hammurabi. Hippocrates (460-380 BCE) and the Greeks also engaged with environmental and community aspects of health including diet, exercise, cleanliness, and sanitation. Epidemics such as bubonic plague in the middle ages encouraged the development of disease control measures like quarantine. The discovery of bacteria in the 17th century, the increase in urban populations during periods of industrial growth in the 18th and 19th centuries, and the emergence of vaccines in 1796 all contributed to increasingly regimented systems of public health.

In the United States, the Marine Hospital Service, later to become the US Public Health Service, was founded in 1798 and the Communicable Disease Center (now Centers for Disease Control) in 1946. Internationally, the World Health Organization was chartered in 1948. For the past several hundred years, increasing understanding of the mechanism of disease and environmental factors in health, as well as increasingly effective medical practice and technologies for infrastructure have all contributed to the development of the modern public health system. Public health workers have played an integral role in disease eradication, occupational health and safety, food safety, motor vehicle safety, anti-smoking campaigns, and disaster relief efforts (“Public Health History Timeline,” 2014). Despite these gains, however, “public health” has also been used to justify unethical and even horrifying historical episodes like the Tuskegee study and Nazi Science.

Public Health and Eugenics
Judge Oliver Wendell Holmes, Jr. infamously claimed that “Three generations of imbeciles are enough” in his US Supreme Court decision for Buck v. Bell, which allowed compulsory eugenic sterilization (1927). Holmes’s preceding sentences, though, provides a window onto a broader conversation about the powers of government to interfere with individual liberty: “The principle that sustains compulsory vaccination is broad enough to cover cutting the Fallopian tubes. Jacobson v. Massachusetts, 197 U.S. 11.” By referencing what has been called “the most important judicial decision in public health” (Gostin, 2005)—the 1905 US Supreme Court decision that the government could compel citizens to be vaccinated against their will—Holmes explicitly connected eugenic policies and public health practices.

Public health historians have shown that agencies in the US and Canada were complicit in programs of eugenic sterilization based on assessment of mental capacity, race, and immigration status (Kline, 2012; Pernick, 1997; Stern, 2005; Strange & Stephen, 2012). Anne-Emanuelle Birn and Natalia Molina address the institutionalization of these practices, claiming that they were not simply perpetrated by unethical fringe scientists, but instead were “fully backed by numerous state and federal agencies and social, political, and academic luminaries.” Ultimately, they note, “Public health and eugenics programs shared the same general goal: to improve the well-being of society, whether by altering the environment or by manipulating the gene pool” (Birn & Molina, 2005).

Max Nordau’s Degeneration, a classic text in early eugenic thought first published in 1892, further clarifies the link between eugenic principles and public health, by citing many factors that fall under public health jurisdiction:

A race which is regularly addicted, even without excess, to narcotics and stimulants in any form (such as fermented alcoholic drinks, tobacco, opium, hashish, arsenic), which partakes of tainted foods (bread made with bad corn), which absorbs organic poisons (marsh fever, syphilis, tuberculosis, goiter), begets degenerate descendants who, if they remain exposed to the same influences rapidly descend to the lowest degrees of degeneracy, to idiocy, to dwarfishness, etc. That the poisoning of civilized peoples continues and increases at a very rapid rate is widely attested by statistics. (Nordau, 1895)

He follows this claim by presenting statistics on the prevalence of tobacco and alcohol, and the negative impact of poor sanitation in cities. The rise of statistical science in the nineteenth century has been linked with increasing interest in “normalcy” (Davis, 2013) and to increasing government interest in collecting information about their populations (Levine & Bashford, 2012). This level of state oversight of populations continued to develop into the twentieth century, which coupled control of infectious disease with eugenic practices through compulsory notification programs for communicable diseases (sexual or otherwise) and, in some places, restrictions on the marriages of those with such illnesses (Levine & Bashford, 2012).

The values behind Buck v. Bell still guide much modern public health practice: prioritizing prevention over treatment, emphasizing the rights of the collective over the individual, and acknowledging that the state is empowered to compel action that won’t be taken voluntarily. Jacobson v. Massachusetts, which in its first hundred years was cited in 69 US Supreme Court decisions on topics ranging beyond eugenics to abortion, end-of-life care, water fluoridation, and more (Gostin, 2005; Pernick, 1997), is thus an important partner text to Buck v. Bell. Jacobson still stands, and so including it in conversations about eugenics can illuminate resonances between eugenic thought and a wide range of contemporary public health issues.

Public Health Ethics and the Problem of Autonomy
Eugenics and its contemporary iterations, like prenatal screening and selective abortion, are constant fodder for bioethicists, who widely condemn eugenics in its most obvious forms, but hotly debate (and often endorse) the value of genetic technologies and neo-eugenic thought. Arguments based around the primary principles of bioethics—autonomy, maximizing goods, minimizing harms and justice—contribute important perspectives to these debates. Shifting the conversation to include insights not just from bioethics but also from public health ethics provides another valuable frame for conversation.

The field of public health ethics is, comparatively speaking, a young sector of applied ethics, not truly recognized until the AIDS crisis and still emerging in the twenty-first century. Its key thinkers have emphasized the key differences between clinical ethics and public health ethics: the former is focused on individual health, the latter on population health; one employs mostly medical means, and the other also utilizes non-medical, social measures. Moreover, public health is more multi-disciplinary and more focused on social justice and health disparities than on distributive justice.

The most typically cited difference between the fields is that clinical bioethics emphasizes autonomy (though this has been complicated by recent scholars working on care ethics) while public health’s focus is on the good of the collective, and recognizes the state’s police power to coerce cooperation (Bayer & Fairchild, 2004; Jennings, 2009; Lee, 2012). These priorities can lead to abuses against the individual in the name of the “greater good”—abuses like those committed against past victims of eugenics and future persons who will be denied life.

Conclusion
Public health must reckon with the legacy of eugenic practices and their modern incarnations. Those studying eugenics can benefit from thinking about eugenics more fully as a public health practice with resonances in contemporary debates over vaccination, quarantine, and other liberty restricting measures.

-Lindsey Grubbs

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• Birn, A.-E., & Molina, N. (2005). In the Name of Public Health. American Journal of Public Health, 95(7), 1095–1097. http://doi.org/10.2105/AJPH.2004.058065

• Davis, L. (2013). Introduction: Disability, Normality, Power. In L. Davis (Ed.), The Disability Studies Reader (4th ed., pp. 1–16). New York: Routledge.

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• Kline, W. (2012). Eugenics in the United States. In The Oxford Handbook of the History of Eugenics (pp. 511–522). Oxford: Oxford University Press.

• Lee, L. M. (2012). Public Health Ethics Theory: Review and Path to Convergence. The Journal of Law, Medicine & Ethics, 40(1), 85–98. http://doi.org/10.1111/j.1748-720X.2012.00648.x

• Levine, P., & Bashford, A. (2012). Introduction: Eugenics and the Modern World. In P. Levine & A. Bashford (Eds.), The Oxford Handbook of the History of Eugenics (pp. 3–25). Oxford: Oxford University Press.

• Mowat, D., & Butler-Jones, D. (2007). Public Health in Canada: A Difficult History. Healthcare Papers, 7(3), 31–36.

• Nordau, M. (1895). Degeneration (Second Ed.). New York: Appleton and Company.

• Pernick, M. (1997). Eugenics and Public Health in American History. American Journal of Public Health, 87, 1767–1772.

• Public Health History Timeline. (2014, June 6). Retrieved April 29, 2015, from http://www.sphtc.org/timeline/timeline.html

• Stern, A. (2005). Sterilized in the Name of Public Health. American Journal of Public Health, 95, 1128–1138.

• Strange, C., & Stephen, J. (2012). Eugenics in Canada: A Checkered History, 1850s-1990s. In The Oxford Handbook of the History of Eugenics (pp. 523–538). Oxford: Oxford University Press.

• U.S. Department of Health and Human Services. (2011, November 10). Where We Work. Retrieved April 29, 2015, from http://www.usphs.gov/aboutus/agencies/