Public health policies can be near-miraculous things. They destroyed polio, and gave us all clean drinking water and strong teeth. But there are occasions when public health policies, when combined with human nature, go terribly wrong. Here are nine of the biggest disasters that resulted.
Photo by Michael Theis
If you've seen any ads for anti-depressants lately, you've probably noticed that many of them include warnings that they may lead to thoughts of suicide, especially in young adults. For unknown reasons, one study showed that people under the age of 25, who took these antidepressants, had suicidal thoughts or exhibited suicidal behavior at twice the rate of those taking a placebo. Companies were required to make this known. Parents found it understandably terrifying, and there a was a major drop in the amount of young people put on antidepressants. Meanwhile, other studies found that these antidepressants either had no increase on the amount of suicide attempts by young people, and, in some populations, a high rate of antidepressant usage corresponded with a lower rate of suicide attempts. Meanwhile, the overall drop in the use of antidepressants corresponded with a small, but significant increase in the number of suicide attempts among younger people.
This is a particular case that illustrates a general trend. In the late 1970s, an exhaustive campaign of vaccination eliminated smallpox in the wild. By 1978, researchers were nearly certain that it had been eradicated, outside of labs. This turned their attention to the safety standards in those labs that still carried the virus. Health researchers were dismayed to see that many of the labs were casual facilities, where workers wore no protective clothing and where they walked in and out of their labs freely, without any seal on the doors. With no pressing need to create new and better vaccines, the World Health Organization required that, past a certain date, any lab that dealt with the airborne virus have expensive safety features that most of the existing labs did not have. This put researchers in those labs under time pressure to finish their research before they had to destroy their samples. They worked with the virus more extensively, and dropped safety precautions. Because researchers in a lab in Birmingham stopped using fume hoods when they worked on the virus, it got into the air ducts. A photographer who worked upstairs from the lab got infected. She was the last person to die of smallpox. Raise safety standards, and people will try to slip below those standards instead of trying to get over them.
Anyone who grew up watching anti-drug commercials knows something essential: it is really hard to make an anti-drug commercial that doesn't make drugs look kind of cool. (It's just like war movies and films about washed-up prize fighters.) To counteract this, the Drug Abuse Resistance Education (or DARE) program was formed. Educators would get groups of kids together, fostering friendships, warning the kids to stay away from hard drugs and alcohol, and making them feeling good about "just saying no."
Follow-up studies showed that kids who were in the D.A.R.E. program in schools were slightly more likely to have tried nicotine or alcohol, and slightly more likely to have lower self-esteem. This is the exact opposite of what the program set out to do. By telling kids that illegal drugs are a surefire descent into hell, campaigns make legal (and comparatively more addictive) drugs look safe. As for the lower self-esteem, by telling kids that drugs are everywhere, anti-drug campaigns make kids think they are missing out, or that they're "the only one" who is not doing drugs.
Abstinence-only education so completely fails to work that it almost seems like an exercise in reverse psychology meant to encourage teen pregnancy. A sweeping study on different abstinence-only programs showed that they almost always result in higher rates of teen pregnancy. Kids who get taught to abstain have higher rates of pregnancy even when the researchers control for the economic status of the teens and the availability of Medicaid waivers for family-planning services.
But all hope was not lost. The study noted that there was one abstinence-only education program that seemed to work. For this program, kids who got comparable amounts of abstinence-only education and sexual education had the same rate of abstinent behavior and unprotected sex. The problem was, "the abstinence-only intervention in that study was unique in that it increased knowledge about HIV/STD, emphasized the delay of sexual activity, but not necessarily until marriage, did not put sex into a negative light or use a moralistic tone, included no inaccurate information, corrected incorrect views, and did not disparage the use of condoms. As a result, as pointed out by the authors, this successful version of abstinence education would not have met the criteria for federal abstinence-only funding." So it was federal policy not to fund the only kind of abstinence-only education that could possibly work to prevent teen pregnancy.
Here's a historical event that still divides public opinion. Did Prohibition turn Americans into heavier drinkers than they'd ever been before? According to some researcher's calculations, yes. Although initially the consumption of alcohol went down, it shot up again in 1922 and reached an all-time high in 1925.
Other researchers disagree. Deaths by alcohol poisoning and cirrhosis of the liver went down starting around the time of Prohibition, and has stayed down ever since. Still, deaths by methanol poisoning, due incompetent or malicious brewers, went up. More importantly, drinking culture shifted to new populations. One population was young people. Teetotalers had been the organic-local-kale-eaters of their day, the kind of trendsters that young people might want to emulate. Once Prohibition was in full swing, non-drinkers changed to the stodgy and oppressive law-abiding folks that young people wanted to rebel against. Younger people started drinking more, and they drank harder stuff. Alcohol consumption also went way up among women. Although the public was generally in favor of law-makers banning hard liquor, few expected them to ban beer as well. This shut down the pubs, which were traditionally male-controlled spaces, and opened the way for co-ed drinking spaces. At best, Prohibition shifted drinking culture to what it is today. At worst, it killed quite a few people while doing so.
The late 1950s and 1960s saw a lot movies about hell-hole mental asylums. To be fair, those movies were relatively accurate. A mental asylum isn't the most pleasant place at the best of times, and over-crowding - sometimes with misdiagnosed patients - made them progressively worse through the first half of the last century. In 1959, about 37,000 people were in mental asylums in California alone. In the early 1960s, the population in asylums began dropping. Doctors in asylums, for the most part, whole-heartedly supported the change. The patients were moved to community care centers, designed to help patients get back on their feet and re-enter society. Those who needed more help got both care and drugs. As budgets were cut, those patients got less care, and more drugs. Some physicians, overwhelmed by the number of patients they had to deal with and pressured by frightened community members, over-used tranquilizers to keep patients quiet and compliant. And budgets got cut further. Eventually, a large, mentally-ill asylum population became a large, mentally-ill homeless population.
Quarantines are excellent ways to keep illness in check. They work best on a small, contained population. A quarantine is, however, rarely an easy policy to institute. Any population is going to protest being forced to stay in an area already filled with contagion. Throughout history, many populations have protested, and many have been successful - especially the wealthy and politically powerful populations. The poor and disenfranchised, on the other hand, had little ability to effectively protest. They also rarely had the power to demand adequate medical care while they were stuck in their quarantine zones.
Since poverty and disenfranchisement are no barrier to having brains, it didn't take long for vulnerable populations to know they were going to get quarantined whenever a particular kind of sickness came to town. A good example of this was people along the Mississippi, in the 19th century, whenever yellow fever struck. Minorities, poor people, and beggars knew that once it got out that fever had hit a city, they'd be all-but walled up, and few people would venture in to treat them. As a result they fled the city as soon as they could, and some inevitably took the fever with them.
The Plague of Justinian was named for the emperor whose efforts to restore the Roman empire ended . . . in the Plague of Justinian. Justinian was the emperor of the Byzantine Empire (or Eastern Roman Empire) in the sixth century AD. He was determined to usher in a new golden age, and started out by declaring war on nearby territories. Once the territories had been subdued, he moved to ensure the health of his city, Constantinople, by demanding grain. Conquered rural regions would send in "grain tax" to feed the poor and keep the city strong and bustling.
Because weather conditions made shipping impossible at certain times of year, the grain was stored in large warehouses, which also housed a lot of rats, which housed fleas, which housed Yersinia pestis - otherwise known as the bubonic plague. Once plague blossomed in the cities, Justinian's success at opening up speedy travel routes around the Mediterranean helped it move all over the region. At the height of the epidemic, 5000 people died in Constantinople every day, and as much as a quarter of the population around the Mediterranean was wiped out.
This particular policy has been tried on everything from cobras to pigs. It ushers in something known as the Cobra Effect, or Perverse Incentive. A government has a nuisance animal that's spread over a large area, and a population that needs to make some extra money. There seems like an easy fix for this. Have people hunt down the animal in their spare time, and make some spare money.
The British tried this with cobras in Delhi, and the French tried it rats in Hanoi, the Americans also tried it with rats in San Francisco. The plant, at first, seems like it will work, but it doesn't take long for enterprising souls to realize that it's easier to breed rats (or even snakes) than it is to hunt them. By making nuisance animals worth something, bounties reward people for cultivating a high nuisance animal population, rather than a low one. Put a bounty on rats to ward off disease, and suddenly people will begin mass-producing rats, and inadvertently mass-producing the disease as well.
[Via National Institute of Mental Health, Antidepressant Suicide Warnings May Have Backfired, Project DARE Outcome Effectiveness Revisited, Just Say No to DARE, Why "Just Say No" Doesn't Work, Epidemiology of the Black Death, Abstinence-Only Education and Teen Pregnancy Rates, Of Rats Rice and Race, Did Prohibition Really Work?, How Release of Mental Patients Began, Lessons from the History of Quarantine.]