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Catching up to Reality on Blood Donations by Gay Men

March 7th, 2010 No comments

When Obama was seeking the Presidency, the GLBT community had a well-defined punch list of action items, and he promised big things on all of them: repeal of DADT; repeal of DOMA (although he doesn’t support marriage equality); passing ENDA; passing inclusive hate crimes law (the only hole punched so far). A few others, notably the administrative implementation of the-then recent repeal of the insane prohibition against HIV-positive immigrants, were perhaps further down on the list, but also up for discussion. Conspicuously absent from the mainstream agenda has been an item of interest to the public health community: lifting of the ban on gay blood donors.

So I was buoyed to see that just a few days ago, a group of sixteen U.S. Senators sent a letter to FDA Commissioner Margaret Hamburg, urging the agency to reconsider its twenty-seven-year-old lifetime ban (“deferral” is the quaint term used, but it’s politely Orwellian in this case) on blood donations for men who have had even one sexual encounter with another man.

The policy is long overdue for an overhaul. As the letter notes, the policy is inconsistent with various other exclusions, and is an artifact of a time when all that was really known of HIV infection — and we weren’t even calling it that, in 1983 — is that it disproportionately struck gay men. Even today, MSM (“men who have sex with men,” which is the term used by the CDC because it focuses on sexual behavior, rather than on orientation) are prohibited, forever, from donating blood if they have had sex, even once, with another man, at any time since 1977. The Senators’ letter points out the many inconsistencies in the policy, including the fact that there’s no exclusion of those who have had high-risk, unprotected heterosexual sex, no matter how recently. Even more absurdly, those who have had heterosexual sex with those known to have HIV are only deferred for one year; not for 33! And “sex” isn’t defined when it comes to MSM: the safest kind of protected sexual acts are, in theory, treated the same as the riskiest.

It should go without saying that none of this can be justified from a public health perspective.

These inconsistencies should be enough to sink the policy which, as the letter notes, has lately been repudiated by the major blood banking organizations, most significantly including the Red Cross. But the problems are much deeper and more serious than even the letter recognizes. A few years ago, I discussed the issue in detail in this law review article. Here, I’ll summarize the arguments I made there that weren’t explicitly raised in the letter.

First, while the CDC is careful to distinguish behavior — men having sex with men — from identity, the FDA policy undermines this sound epidemiological distinction by effectively collapsing the two. By excluding any man who’s had any kind of “sex” (not defined!) with even one other man during the past thirty-plus years, the FDA has created a policy that isn’t about relevant behavior, but about some weirdly expansive view of (gay) sexual orientation. Because if it were about behavior, the line would have been drawn in an entirely different place; say, for a year after specifically identified, high-risk behavior.

Second, the policy undermines trust in public health in a few related ways. Obviously, as a practical matter the policy isn’t enforceable, and the sheer breadth of it has doubtless caused many to ignore it. People aren’t stupid: Gay men who know they have an HIV-negative serostatus might give blood, understanding that they pose no threat. (According to this very unscientific poll over at 365gay.com, almost 200 of 800 respondents admitted to having lied about their sexual practices on the questionnaire.) But by attempting to fence them out, the FDA has sent gay men an unwelcome message that could undermine the community’s trust in other ways. One important public health principle is that it recognizes the long-term value of respecting the dignity of all populations.

Why has the policy persisted for so  long? One argument seems sensible, at first blush: If the exclusion were changed to, say, one year, there would be some infinitesimal increase in the number of HIV-positive blood transfusions (well less than one in a million, it’s estimated), so why do anything to increase the risk? But the “let’s not do anything if there’s a tiny risk of harm” canard — which, by the way, is also prevalent in arguments against marriage equality — wouldn’t be, and hasn’t been, applied to any other category of people, or of conduct. Of course there will be some tiny uptick, not  because of the three-week window period between infection and ability to identify it, which any contemplated new rule would  easily accommodate, but because of the irreducible human error associated with the process: If you add more people, some will get through who should not. But this could be said of any proposal to add donors; it’s just that “MSM” have had such a draconian policy applied to them for so long that the donor baseline is essentially zero for this group.

It seems that uprooting this policy is fairly far down on the priority list for the LGBT community. Indeed, this story seems to have attracted but little attention. But messages matter. The radical, embarrassingly outdated FDA policy sends a terrible signal that ought to concern us. It’s good to see that someone is finally suggesting action. Will Obama back them up?

Rachel Maddow and John Birch at CPAC

February 19th, 2010 1 comment

CPAC 2010 – A Conversation with Rachel Maddow

Watch the conversation between Rachel Maddow and a couple of guys from the John Birch Society (including President John F. McManus) on the Society’s webpage here. Is there a more charismatic television personality than Maddow out there today? You can tell how much she’s enjoying herself, how relaxed she is, and how well she understands the importance of actually talking to people with whom you most strongly disagree. (Compare: the lately unwatchable Keith Olbermann, who (just for instance) compared the Supreme Court’s corporate financing decision to…Dred Scott?!…in one of his increasingly embarrassing “Special Comment” segments. And this is a guy I mostly agree with!)

These John Birch nuts opposed the fluoridation of drinking water; listen and watch how well Maddow discusses the point with them, and how she somehow manages to resist arching her eyebrows when McManus discusses his view that there’s a straight line between forced fluoridation and (wait for it!) putting birth control substances into the public water supply. (Nuanced, these guys aren’t.) You might even learn something about iodized salt. All in all, a quick miseducation in public health.

Who’s Left to Love?

February 15th, 2010 No comments

This depressing article in today Philadelphia Inquirer relates a familiar tale: The poor are being vilified for taking government money, blamed for having made bad choices, called “breeders” for having kids they can’t support (with an icky overlay of moral disapproval for having many of these children out of wedlock). As the story points out, much of the anger is diffused and untroubled by facts: welfare rolls have been slashed mercilessly since the so-called Welfare Reform Act of 1996; the payments are so meager that no one would seek this as a viable means of support (and it lasts five years, max, anyway); most of those receiving assistance are children.

The anger is sometimes startling, as when South Carolina Lt. Gov. Andre Bauer recently compared the poor to “stray animals who breed,” or when pandering, no-nothing politicians make symbolic shows of making life even more humiliating for people who can’t get by:

Pennsylvania State Rep. Garth Everett (R., Lycoming) has tried for a year to pass a law that would have [Temporary Assistance to Needy Families] recipients drug-tested and fingerprinted, a practice in some states. “People’s wallets are tighter these days, and they don’t want funds going to folks with drug problems,” he said.

Asked to back up his claims, Everett said, “I don’t have evidence that people are using it [TANF money] to buy drugs. I do get feedback from a significant part of my constituency that they have the feeling that folks on welfare are using drugs.” He added that his proposed bill “is not going anywhere” because Democrats oppose it.

His constituents “have the feeling” that folks are using money — some of the very generous $403, per month, for a mother and two kids — to buy drugs. That’s enough for Everett, who can make a political show of his solidarity with the angriest elements of his constituency without having to deal with the consequences. Among them is the likelihood that the money spent on drug testing and fingerprinting would far outweigh any cost savings from denying benefits to those using drugs, and thereby end up costing the state more money. As a bonus, it would feed into the discredited view that  drug addiction is a matter of choice and not a medical, public health issue that requires complex intervention.

Given that the poor take such a tiny percentage of the state’s money, the anger isn’t really about the money. It’s more the product of a deep and justifiable frustration by the broad swath of the increasingly left-behind middle class that they’ve done everything right, but can’t get ahead. Like a tire skidding endlessly on ice during our tundra-like winter here in the Mid-Atlantic, they work harder and harder and fall further and further behind. So to them, anyone who gets anything for “nothing” is bound to be the target of some vitriol. But would they change places with those they condemn?

No, they’d rather change places with the Wall Street bankers and financiers whose complex machinations were a significant contributing factor in the national and global meltdown that continues apace. But they know that’s not possible, and they’re too beaten down — and realistic — to think that people as well-connected as these modern-day robber barons (there! I said it! let the angry responses begin) will be brought to heel, or even asked to cut back by one yacht. Government is detested, but there, too, the problem seems too big and complex for them to have any effect.

This culture of fury and jealousy, whatever its understandable origin, isn’t healthy. I might want to blame right-wing talk show hosts like the morbidly obese Rush Limbaugh who, without apparent irony, recently wailed about how food stamp recipients are spending their money on unhealthy choices (including the outright lie that some of it is going to booze; it can’t), but the most accurate thing to say is that they’re only amplifying resentment and confusion that’s already out there. (If you want to make a symbolic stand against the worst (and most effective) offender, join this Facebook group).

As Sarah Palin understands (and she doesn’t understand much), there’s a fortune to be made in tapping into this anger. Obama, meanwhile, has the more difficult responsibility of connecting with our deeper but often less accessible sense of community and collective responsibility. He’s not always done this effectively, unfortunately, but this is the area in which we really need that “hope-y, change-y” thing. Otherwise, I fear that “the centre cannot  hold.” While I’m on Yeats, here’s a tired but apt close:

The best lack all conviction, while the worst
Are full of passionate intensity.

Religion, Assimilation, Vaccination

February 9th, 2010 1 comment

According to this story, an outbreak of mumps has occurred in counties just north of New York City, mostly in Orthodox (or Hasidic) Jewish communities, where parents routinely seek religious exemptions to vaccination requirements for their children. In total, about 1,000 kids (mostly adolescents) have been afflicted.

When I was a kid, we all came down with mumps, and more: measles, chicken pox, and so-called “German measles” (rubella) were the most common. Mostly, these were cause for missing a week or so of school, but nothing more. Yet all of these diseases are properly seen as deadly threats to the public’s health. Measles, which is particularly likely to spike in a population where a significant number go unvaccinated, routinely killed many hundreds of kids each year in the U.S. alone, caused about double that number of permanent brain injuries, and cost the health insurance system dearly through the many thousands of hospitalizations. Mumps, in addition to the quasi-endearing chipmunk cheeks we all had, was most often associated with deafness as a complication.

The outbreak sits at the confluence of two infuriating obstacles to vaccination: bad science and over-deference to religion. Apparently, the outbreak in the U.S. was an unwanted import from the U.K., where a mumps outbreak had spread to some 4,000 people. Vaccination exemptions are frighteningly common there, mostly because of a thoroughly refuted study that purported to show a link between vaccinations and autism. Indeed, the prominent British medical journal that had published the study, the Lancet, last week retracted it after a British medical panel concluded that the lead author had been unethical and had conflicts of interest. And a flood of other studies since that one had already disproven its autism-vaccination link.

Once mumps made its way into the U.S., the congregation Orthodox and Hasidic Jews proved fertile ground for its spread. One locus was an area within Rockland County, New York, where a large, insular community of Hasidic Jews lives. I grew up in Rockland (in a nearby town), and know the community. On a Saturday, we’d drive past the synagogue-going residents — all on foot, the men in simple black garb with a defining hairstyle, the women in long dresses with head covering. Quite an insular community, and one in which, (credible) rumor had it, the families didn’t pay property taxes on their homes (each being considered a holy place). So there’s one exception from general laws that they enjoyed.

I didn’t know until recently of this other exemption for vaccinations, and I don’t support either carve-out. (In my view, no church should be exempt from paying property tax in the first place. There’s another whole post there, but I digress.) Respecting religion doesn’t require subjecting the public to needless risk. Quite the contrary: Religion is honored when we find and protect a proper, separate space for it. But personal or congregational religious expressions should end where the interest of the general public — a secular interest — is imperilled. Thus, it’s hard to justify a ban on the burka in public spaces (compare, say, driving, if evidence showed that the compromise to peripheral vision was significant), but equally hard to justify allowing the adherents of any religious group to forego vaccination. It’s easy to forget the public health success story of vaccinations. This recent story on those confronting new challenges from polio, many decades after they were first afflicted, should be reminder enough — but probably won’t be.

What’s the public health threat if everyone else is vaccinated? First, there’s the threat to the unvaccinated children themselves. The state has an interest in them, too, and at least one state supreme court has held that this interest makes unconstitutional any non-medical exemption. Beyond that, the vaccinations are themselves not completely effective. Thus, even the vaccinated kids can come down with the illness in question; and some of them will if a sufficient number in the population is not vaccinated. So it’s not “just” a question of getting to decide what to do about your own child’s health, an issue that the state has an interest in anyway.

When they first enacted religious exemptions to vaccination requirements decades ago, states did do under duress: Congress tied recognition of such exemptions to federal funding. It’s time to wake up and repeal these laws before we undo this great public health accomplishment.

U.S. Government: Compensate Katrina Victims

November 21st, 2009 1 comment

The recent news that a federal judge has ruled the U.S. Army Corps of Engineers, and by extension, the U.S. Government, liable for at least some of the preventable disasters associated with Hurricane Katrina should lead the government to do what it should have done long ago: Provide generous, long-tail assistance to help the residents of New Orleans get back on their feet.

To see why, just take a moment to compare what “we’ve” done for victims of another disaster: September 11. In that case, the Victim Compensation Fund was created to pay not even the survivors of that horrific event, but their families — in some cases, to the tune of millions of dollars. In all, the Fund spent just under seven billion dollars in taxpayer money for an event that the government was not responsible for.

With respect for the victims of that tragedy, I argued against such lavish compensation here and here. Part of the motivation was to avoid potentially crushing liability against  the airlines for their dismal security procedures,1 but that would have better been done through a direct bailout of those industries. Wait! We’d never bail out a failing company.

By contrast, the government awarded only the minimal payments available under federal disaster relief to Katrina’s victims, despite documented negligence (or worse) on the part of state, local, and federal government. And  the federal government, rather than defend the suits against them on the merits, has raised every possible procedural argument. First, they argued that they couldn’t be responsible for the flood-induced breaches of levees that the Corps had built or maintained, because of the Flood Control Act of 1928. That Act does clearly provide governmental immunity in connection with flood control projects, so the court held that the statute barred some of the claims.

Other claims, though, were based on acts of shocking negligence in connection with the maintenance of the White Elephant known as the Mississippi  River-Gulf Outlet (MR-GO), a navigation short-cut from New Orleans to the Gulf of Mexico. Here is a good summary of the allegations of negligence,  which were accepted by the court after a long trial:

The claimants alleged the government failed to properly design, construct, operate and maintain the MRGO, a 76-mile man-made ship navigation channel that connects the Gulf of Mexico to the Port of New Orleans Inner Harbor Navigation Canal. The claimants further alleged that the design of the MRGO (with the surface width being wider than the bottom width), along with the inevitable widening that would occur from waves in the channel, allowed the MRGO to act as a “funnel” for the Hurricane Katrina storm surge. Additionally, the salt water that was allowed to enter the MRGO from the Gulf allegedly killed off the storm-slowing plants and vegetation, further contributing to the “funnel” effect for the storm surge.

Since MR-GO isn’t a flood control project, the immunity probably doesn’t apply. But because of where MR-GO is situated relative to the damaged and destroyed neighborhoods, only residents in the Lower Ninth Ward and St. Bernard Parish were able to recover. Others are out of luck.

The government is considering an appeal. If one is filed, the brief would likely argue that the more general immunity under the Federal Tort Claims Act protects them. Interpreting and applying that immunity is challenging (for reasons that would numb any and all non-lawyers, and many lawyers as well), but my guess is that the judge’s opinion on that issue would stand.

The Government is likely afraid of the many millions of dollars it might have to pay out once others join the suit. But anyone who hasn’t already filed is barred by the statute of limitations. So the total payout that would be required isn’t clear; and in any event almost surely wouldn’t approach the amount paid out for 9/11.

Here’s a radical idea, government lawyers (Obama Administration): Settle the case! Offer structured payments. Set up enterprise zones and incentives for loans to start-up businesses. Build homes for people.  Rebuild the private medical and public health infrastructure. Such initiatives are long overdue. I have mixed feelings about tort liability against the government in any case, but surely some kind of considered, carefully designed compensation has by now become a national imperative. It won’t erase this national disgrace from our history — nothing can, or should — but it would be a compelling show of compassion.

  1. So now we have to divide our personal hygiene products into small bottles in order to board a plane.

Of Oysters and Mammograms

November 20th, 2009 No comments

“I can’t believe they would put an economic value over the lives of fifteen or more people.” (Statement of a woman whose father died as a result of eating raw oysters that contained a deadly bacteria.)

“Let the rationing begin.” (Rep. David Camp, Ranking Republican on House Ways and Means Committee, responding to U.S. Preventive Services Task Force Report that recommends women delay routine mammograms until age 50).1

Public health takes a beating again.

In the first case, the FDA has had to eat crow. Just last month, the agency trumpeted its “public health” duty to prevent a predictable number of deaths each year by banning the sale of untreated, raw oysters during the summer months. But now the FDA has been shut up by the industry and by too-powerful Louisiana Sen. Mary Landrieu. (She can pretty much get anything she wants, including her own Mardi Gras Float, at least while the health care reform bill is pending.) The agency has slunk away, murmuring something about studying “feasibility and costs.”

In the second case, the jumpy recommendation against routine mammograms (and self-examinations) to detect breast cancer has brought a howl of protests. The objection: “Yes, the test only picks up one cancer case out of every 1,900 — but what if you’re the one?” For opportunists in the Camp camp, this cold-blooded calculation serves as a timely, exploitable proxy for everything  that’s wrong about health care reform. Never mind that the proposed legislation does a dismal job at controlling anything — costs or procedures — and that rationing is a fact of life now under managed care.

And when it comes to the battle against breast cancer, stirring outrage is a pink breeze.  Anything that would lead to even one more death — period — will be decried as the heartless elevation of population-based data over real lives.

It’s not clear that federal authorities, here representing a population-based, public-health perspective, were right in either case. Perhaps they could have continued efforts at education in the first case (which the FDA said it had tried, without success for a decade), rather than requiring irradiation (which has its own PR cost). In the second case, even public health authorities are split on whether the evidence justifies the new recommendations. At least this was a non-binding task force, easily overcome by political outrage.

There are two issues here. First, public health works best when it can explain and justify its position in a way most reasonable people will find at least defensible. Even then, though, its recommendations — or even coercive steps — can be defeated when other forces (like the oyster lobby or the breast cancer survivor community) are more powerful.

But the more important point — and the one no one wants to discuss — is that we do make safety and efficiency trade-offs, all the time. We couldn’t function without doing so, either in our own lives, or societally. Would routine mammograms be cost-justified if, say, they saved one life in one million? One can always say: “What if you’re that one person?”

  1. The quote appears in Gail Collins’ reliably insightful and amusing column.

China’s Public Health Challenges

November 14th, 2009 No comments

China’s political and environmental challenges are often chronicled, but less attention has been paid to the public health issues that the nation’s move to developed nation status has caused.

That’s starting to change. In a good summary article in Yale Public Health, (pdf. of Fall issue on right side of linked homepage), Christina Larson offers a succinct account of the many issues confronting public health researchers and policy-makers in a nation with more than 170 cities of at least one million people (that’s right). As in any rapidly developing nation, China finds itself with a spike in chronic disease problems, while infectious disease issues have to an extent been dealt with. Today, the country is dealing with a high incidence of lung cancers (caused by a just silly smoking rate and by environmental toxins); diabetes; and — yes — obesity. Those iconic Beijing bikes are quickly giving way to cars, with the host of predictable negative health consequences you might expect.

The article goes on to explain that China is really a host of sub-populations, flung over a vast expanse and with wildly different problems. Interventions need to be carefully targeted to stand any chance of improving public health outcomes, but that targeting is itself challenging because of the dynamic, quickly changing nature of the nation and its people. Trying to glean useful data that screens out the “noise” is always a challenge for epidemiologists, but even more daunting under these conditions.

Steps are being taken, including the bellwether move of banning smoking in certain bars, but it will be vital for local, state, and global public health officials to “get smart” about the challenges they face, and soon. Time’s not on their side.

With these issues in mind, a contingent of health law professors from our law school is traveling to Southwest University in Chongqing next month, there to discuss, among other topics, global public health. Our expert on these issues, Michele Forzley, is a global public health expert with ties to WHO and the U.S. Department of Commerce; she is to speak on training legal and public health experts on confronting emerging issues. Her work is vital.

Death Panels? That’s Nothing!

October 25th, 2009 2 comments

Those “death panels” that certain crazies decried weren’t that at all, but ways  of providing incentives for physicians and patients to give serious thought to end-of-life planning. This trumped-up outrage was enough to kill the provision, though.

Here’s some good reporting in the Times on rationing of care, even at the cost of death to some, during a public  health emergency, such as, say…a flu pandemic. I’m not at all sure that the rules spelled out here make the best choices, but make them we must in certain situations. Are you surprised to learn that New York State has a “pandemic ventilator allocation plan”? I was, too, but the Empire State (and neer has a nickname seemed so apt) is not alone in anticipating the need to make decisions no one ever wants to make; the article points out that many states, as well as the Veterans Health Administration, have done the same.

Unlike the excoriated “death panels,” though, these killer plans have largely slipped  through tedious bureaucratic procedures, unchallenged. But what do you think would happen if we ever had to start ripping ventilators away from people’s faces in order to save others? Doesn’t this deeply unsettling bioethical problem call for much more sunshine than it’s gotten?

The Public Health Peril in Oklahoma’s Anti-Abortion Obsession

October 18th, 2009 1 comment

Nan Hunter has just run a good summary of recent legislation in Oklahoma that, taken as a whole, is designed to prevent women from having abortions altogether. The state’s determination shows that, Roe v. Wade not to the contrary, there’s plenty that states can do to restrict what the Court has declared to be part of a fundamental right to self-governance, privacy, and autonomy.

The state’s zeal, though, shows that ideologues on a mission can wreak havoc with settled public health principles, thereby jeopardizing the public’s trust in health care — just in case there’s any such trust left. There are at least two recent examples of this misguided approach.

First, a recent piece of legislation — later declared unconstitutional — required women to undergo an ultrasound (vaginally in the case of early pregnancies) before an abortion could be performed. Such coerced invasion of the body has typically been required only in cases of epidemic; even there, often the resisting party can usually forego vaccination and pay a fine, or suffer the less objectionable deprivation of liberty. This would have been the first case I’m aware of where an unwanted, invasive procedure would have been made a prerequisite for a procedure that someone has a legal right to have, and where that first procedure isn’t needed for some other medical reason. In other words, this is quite different from requiring a biopsy before surgery to remove a tumor.

Laws educating women about fetal development (although also typically a smoke-screen for restricting access to abortions) are OK with me, at least in principle. This weird law, on the other hand, is creepy and offensive, and it’s lucky that the legislators blew it through a technicality (shoving too many subjects into a single piece of legislation).

The second, and more recent example, is a law currently under challenge. This one  would set up publicly available, web-based reports on anyone who obtains an abortion. The information would have to be reported to doctors, who would then be required to pass it on to public health officials. This is a very, very bad idea. I don’t even need to talk about abortion (thankfully!) to explain why.

This law will drive a wedge between physicians and their patients. Many people have distrust of the medical and public health professions, and won’t be warmly encouraged to make that next visit to their provider — or to any other — when they’re met with a battery of identifying questions that can then be used to pick them out of a probably hostile community. As a flimsy subterfuge for the laws’ true intent, names aren’t required — but, as a lawyer from the Center for Reproductive Rights has pointed out, names won’t be needed to identify someone from sufficiently small communities, especially when so much other identifying information is exposed. According to this article, quoted extensively by Hunter, there will be “answers to 34 questions including…age, marital status and education levels, as well as the number of previous pregnancies and abortions. Women are required to reveal their relationship with the father, the reason for the abortion and the area where the abortion was performed.”

It’s clear that the legislators are trying to slap a different kind of scarlet “A” on these women, hoping that the shame and ostracism of expected discovery will keep them from carrying out their intended abortions. It might have this effect, but the more sweeping result will be a lack of trust that will penetrate relationships between patients, doctors, and public health practitioners. Patients will learn how to lie their way around the obviously unenforceable law (some of the facts sought depend on patients’ willingness to disclose, such as “reason for seeking the abortion” and, often, the number of previous pregnancies), and doctors may be less than forthcoming with public health officials if they see them as interfering with the MD/patient relationship. And any public health official with good training will despise and, one thinks, try to circumvent the law.

Even in states that require doctors to report HIV infection to public health, the goal is partner notification and contact tracing to eliminate an established risk. These laws are controversial, but they at least have arguments to recommend them — and the results aren’t published on public websites.

With this level of identifying information, the Oklahoma statute looks more like the sex-offender laws (which have their own problems, btw) than anything else. What more do you need to know?

A Smoke-Free World?

September 25th, 2009 1 comment

I’ve just learned that, beginning in mid-2010, my school will join many others in establishing a completely smoke-free campus. No tobacco anywhere, even in your own car.

http://www.tobaccofreeutah.org/images/large_sign2icon.gifHow far we’ve come. I’d be hard-pressed to think of another common human activity whose social meaning has changed as radically over the past couple of generations. When I was working at a big ol’ NY law firm in the mid-80’s, the smokers among the junior associates were accommodated by getting their own office — three of them packed into a box barely large enough for two, with smoke billowing from the room at every hour of the day and night. But this accommodation was already a major improvement from the pervasiveness of smoking just a short time earlier: Watch any episode of Mad Men from the mid-1960’s, and you’ll see my point.

At Widener, as at many other schools and workplaces, smoking has been driven out by degrees, starting about 20  years ago: First, from common indoor areas; then out of private offices; then from general permissibility outside to restricted areas; and finally to a complete ban. Of course, state legislatures and local city authorities have been proceeding along the same course, with fewer and fewer places available for the smoker to get that fix. Indeed,  when I was in NY a couple of weekends ago for a conference, I was astounded and put off when I was given a smoking room — without notice or choice, at that. “Smoking room? What year is this?” I’d  assumed that such rooms no longer existed. They likely won’t for  much longer.

But why is this happening? The evidence on the harms caused by second-hand (or “environmental”) smoke is fairly strong, but that doesn’t explain the more extreme forms of the ban. It’s very unlikely that folks walking past a few people smoking outside are going to suffer any adverse health consequences. And there’s no reason, along those lines, for prohibiting people from smoking in their own cars.

So what, if anything, justifies the campus-wide ban on smoking and similar measures by state and private actors? Opponents argue, with some justification, that these blanket approaches are nanny state (or analogous private) intrusions on their personal autonomy and right to decide what to do with their own bodies. What’s next, stopping us from eating Snickers on campus?

I have some sympathy with this view (more so when the state is involved), but there’s another aspect to the public health, population perspective that isn’t as often considered: The harder it is to find places to smoke, the likelier it is that people will quit. Given the enormous financial and social cost of smoking, there’s justification for initiatives that discourage people from lighting up.

But it’s crucial, in such cases, to respect those that you’re about to coerce, as by offering them smoking-cessation programs and support. No habit, including heroin addiction, is harder to break. So by changing the social environment, we provide another tool for the construction of what we hope will one day become a smoke-free world. This would be one of the best health care reforms achievable, and the cost savings alone would make the rest of the debate much easier.