Presidents and Public-Health Crises
Over the course of the 20th century, the United States faced three major public-health crises: the polio epidemic, excessively high smoking rates, and HIV/AIDS. Each of these crises took place over a multi-year period, and multiple presidents dealt with both their effects and the national response to them. Nonetheless, certain presidents came to be specifically identified with each of these crises: Franklin Roosevelt and polio, John F. Kennedy and smoking, and Ronald Reagan and HIV/AIDS.
Each crisis posed quite different challenges. In polio and AIDS, the nation faced terrifying and mysterious diseases that required the mobilization of the private and public sectors toward finding cures and disseminating accurate information. With smoking, new information revealed secret dangers lurking in a popular product previously thought to be harmless; and, while the news saved millions of lives, it posed an immediate threat to the national economy. Each health crisis came with its own rhetorical challenges as well, beyond just raising awareness. And, with each new public-health crisis, each of these presidents faced a public with growing expectations about the government's responsibility for solving the problem.
As the United States grapples with its latest public-health crisis — obesity — there is much to learn from the national responses to polio, smoking, and HIV/AIDS. Though Roosevelt, Kennedy, and Reagan all faced different challenges, how they handled the crises is instructive for determining how the U.S. has dealt with public-health crises in the past, and for determining how to address new public-health challenges in the future.
POLIO AND FDR
Of the three presidents who came to own the public-health crises in question, FDR is most closely associated with his, that of polio. This is, of course, because Roosevelt himself was a victim of the dread disease, coming down with it in 1921 at the age of 39 at his vacation home in Campobello. FDR's doctor, W. W. Keen, paid a house call and misdiagnosed the illness — twice — and then charged Roosevelt $8,000 for the misdiagnoses. The illness paralyzed Roosevelt's lower body.
Roosevelt became president despite his illness. While today we associate Roosevelt with polio, it is important to remember that Roosevelt worked hard to make sure that the voting public did not know the full extent of his condition. As David Blumenthal and James Morone put it, "FDR's public life after polio focused on denying his illness." We can see how successful he was in this effort by the fact that Roosevelt, despite being one of the most frequently depicted presidents on the silver screen, was never shown in a wheelchair as president until the musical Annie was adapted for film in 1982. For non-musical depictions, movie fans would have to wait until the 2001 film Pearl Harbor to see FDR as a wheelchair-bound president.
Polio was devastating not just to Roosevelt, but to the entire nation. Polio first appeared in the United States in 1894, but didn't become a recurring problem until the 1940s and the early 1950s, when it crippled about 35,000 people annually; the disease hit its peak in 1952, with a record 57,628 polio cases. The numbers themselves, however, do not convey the full intensity of the crisis, which panicked millions of parents and children alike every year.
As president, Roosevelt took a philanthropic approach to dealing with polio. By the time he moved into the White House, he had already started a foundation in 1927 in Warm Springs, Georgia, run by his colleague Basil O'Connor. Roosevelt had discovered the restorative powers of the warm springs for polio sufferers and became an evangelist for their use. Once Roosevelt became president, he worked with O'Connor to begin a series of "Birthday Balls" to raise money for polio victims. The first ball took place on Roosevelt's birthday in 1934 and raised $1 million for the Georgia Warm Springs Foundation. Four years later, Roosevelt created a new charity, the National Foundation for Infantile Paralysis. The annual Birthday Balls helped to fund the newly formed NFIP, as did its grassroots fundraising campaign, the March of Dimes. (The NFIP eventually adopted the name of its popular fundraiser.)
Roosevelt used his presidential pulpit to promote his philanthropic efforts on polio. In January of 1944, he used martial language to speak to the nation about a war on polio, and made an explicit analogy to the nation's ongoing efforts in World War II: "The dread disease that we battle at home, like the enemy we oppose abroad, shows no concern, no pity for the young." Despite the strong words, Roosevelt's request was for donations, not military sign-ups. As Roosevelt put it, "The generous participation of the American people in this fight is a sign of the healthy condition of our Nation."
In Roosevelt's case, his use of the radio to promote the fight against polio was a sign of how seriously he took the disease. This was before the days of the president's weekly radio address. Roosevelt, despite being known as a master of radio, took to the airwaves relatively infrequently, in an effort to avoid overexposure. Even his famous Fireside Chats, which revolutionized the political use of radio, usually only took place two or three times a year. If Roosevelt was using one of those rare opportunities to promote polio research, it showed that combating polio was one of his top priorities.
The March of Dimes recognized the importance of Roosevelt's efforts to its success. In an official history, March of Dimes notes that "efforts to launch the March of Dimes were boosted by radio, Hollywood, and the personal appeal of the president." And the March of Dimes put its funds to good use. A 1943 grant from the NFIP to the U.S. Army Neurotropic Virus Commission for studying polio in North Africa helped provide funding for researcher Albert Sabin. Sabin would go on to create the oral polio vaccine, which followed the discovery of the original polio vaccine in 1952 by Jonas Salk, himself a March of Dimes grantee.
O'Connor announced the discovery of the polio vaccine on the 10th anniversary of Roosevelt's death. According to FDR biographer Conrad Black, the development of the vaccine stood as "Roosevelt's ultimate victory over his illness." In addition, according to Black, Roosevelt's fundraising on behalf of polio research was so important that the discovery "would not have occurred, at least until decades later, without him." Roosevelt's use of his stature and his own considerable communications talents constituted a successful and non-government focused approach to a severe public-health crisis. March of Dimes also helped fund distribution of the vaccine, and in 1955 President Dwight Eisenhower announced plans to help states fund distribution of the polio vaccine.
Creation of the vaccine changed everything when it came to polio. The 14 years from 1937 to 1950 saw about 230,000 cases of polio in the U.S., which is about the number of cases that would appear over the next 50 years. In recent years, polio has become even more infrequent. Naturally occurring polio has not appeared in the U.S. since 1979, and that case occurred within the vaccine-skeptical Amish community. The NFIP quickly became obsolete, so the organization changed its name and its mission; the March of Dimes now focuses on birth defects.
SMOKING AND JFK
Rarely does a public-health campaign ever so completely eradicate a public-health threat as was the case with polio. But there have been instances of public-health campaigns reducing threats, and even changing societal behavior. In 1962, for example, President Kennedy directed Surgeon General Luther Terry to create an Advisory Committee on Smoking and Health. This effort came in response to a 1961 letter to Kennedy from the American Cancer Society, the American Heart Association, the National Tuberculosis Association, and the American Public Health Association asking him to look into the health effects of smoking. The committee, comprised of 10 expert scientists, met nine times over the next two years to review the scientific evidence regarding smoking.
The committee's report came out in 1964, the year after Kennedy's tragic assassination in Dallas. The report found that smoking was deleterious to one's health, and even specified a 70% increase in mortality among smokers over non-smokers. At the time, these were controversial findings. Terry intentionally timed the release of the report for a Saturday, so as to minimize the report's impact on the stock market. Even so, Terry recalled, the report "hit the country like a bombshell. It was front page news and a lead story on every radio and television station in the United States and many abroad."
As a result of the committee's report, official U.S. government policy since then has been to oppose smoking, and it has done so in a variety of ways. In 1965, Congress approved a warning label on cigarettes. Beginning in 1970, the warning was issued in the name of the Surgeon General. And since 1970, the government has banned tobacco advertising on both TV and radio. Furthermore, the campaign against smoking has been a continual effort of the office of the Surgeon General, with some Surgeons General, particularly Dr. C. Everett Koop under Ronald Reagan, making anti-smoking efforts their signature cause.
The government's anti-smoking efforts have had a real impact. In 1964, the year of the initial Surgeon General report warning of the dangers of smoking, over half of U.S. men — 52.9% — smoked, along with 31.5% of women. By 1970, when the advertising bans went into effect, those numbers had dropped to 42.3% for men and 30.5% for women. By 2014, according to the Centers for Disease Control, smoking had dropped to 16.8% of all U.S. adults, 18.8% of men and 14.8% of women.
Even with these dramatic behavioral shifts, tobacco smoking continues to have a real health impact in the United States. Almost 40 million Americans still smoke, mostly among the young and the poor. According to the CDC, smoking still causes over 480,000 U.S. deaths annually — one of every five deaths. The economic impact of smoking remains considerable as well: more than $300 billion annually, split between nearly $170 billion in medical costs and $156 billion in lost productivity. Still, these figures would have been much higher without the concerted effort by the United States government over the last 50 years to reduce smoking, an effort stimulated by that letter to President Kennedy in 1961.
HIV/AIDS AND REAGAN
During President Reagan's tenure, the United States was dealt another public-health crisis: HIV/AIDS. Unlike smoking, which had long been on the agenda of public-health organizations, HIV/AIDS caught America and the world by surprise. Throughout the 1980s and early 1990s, HIV/AIDS cases and annual deaths skyrocketed, from 451 deaths in 1981 to 50,628 in 1995. The mysterious and fast-moving illness shocked people, and devastated entire communities. Over 19,000 New Yorkers alone died of AIDS-related causes in the 1980s. Overall, about 698,000 Americans have died from AIDS, more than the 675,000 deaths from the Great Influenza of 1918.
The surprise emergence of AIDS created considerable controversy about whether the U.S. did enough to combat it in its earliest years. In a piece written shortly after Reagan's death, the New York Times' Robin Toner and Robert Pear wrote that "Advocates for people with AIDS have long asserted that Mr. Reagan's lack of leadership on the disease, which was first reported by the Centers for Disease Control in 1981, significantly hindered research and education efforts to fight it." Randy Shilts, whose 1987 book And the Band Played On helped establish the image of a Reagan disengaged or even hostile to combating AIDS, wrote that "Reagan had never publicly spoken the word AIDS or ever alluded to the fact that he was aware that an epidemic existed." After Nancy Reagan's March 2016 death, Hillary Clinton was blistered by the left for even suggesting that President and Mrs. Reagan "started a national conversation" about AIDS in the 1980s.
Others have made the case against Reagan on HIV/AIDS far less judiciously. AIDS advocate Larry Kramer has called the 40th president "Adolf Reagan," and said that "the world would have been better off if he [Reagan] had not been president." Building on his Hitler theme, Kramer has called Reagan "a monster and, in my estimation, responsible for more deaths than Adolf Hitler." According to the pro-Reagan author Steven Hayward, "Leftist attacks on Reagan over AIDS would come to compete with civil rights agitators to reach the furthest hyperbole." Historian Gil Troy, who has acknowledged that "President Reagan was slow to address the [AIDS] issue," has also decried the unfortunate phenomenon of "AIDS activists accusing the Reagan administration of complicity in a gay genocide."
The case against Reagan on AIDS is well known. But does it correspond to the reality? According to Gary Bauer, the Reagan domestic-policy aide often painted as the villain in this saga, U.S. spending on HIV/AIDS research increased under Reagan's watch, and Reagan's relative silence on the issue stemmed from his philosophical belief in cabinet government, in which the Surgeon General should lead the charge on public-health issues. On the first point, funding definitely increased, as the U.S. government spent over $5.7 billion on HIV/AIDS under Reagan, a level that would later be designated as "disproportionate" in relation to other diseases. The columnist Deroy Murdock looked into the dramatic increases in AIDS funding under Reagan and concluded that "Reagan's signature inaugurated federal action on AIDS research and treatment" (emphasis in the original).
On the second point, Surgeon General Koop was indeed outspoken on AIDS. In addition to smoking (as discussed above), Koop also made a big splash with his statements on AIDS. However, according to journalist Carl Cannon — son of top-notch Reagan biographer Lou Cannon — "Contrary to the prevailing wisdom, Reagan dragged Koop into AIDS policy, not the other way around."
Furthermore, Reagan may have been slow in getting a complete handle on AIDS, but he was not alone, and he was not shy about the issue once he caught on. According to Richard Reeves, contrary to suggestions Reagan was unaware of the issue, "he obviously did know about the AIDS debate going on in the White House" in 1986. In early 1986, he visited the Department of Health and Human Services — a relatively rare step for a president — and told staffers there that "one of our highest public health priorities is going to be continuing to find a cure for AIDS." The next spring, in April 1987, he declared AIDS to be "public health enemy number one."
Regardless of one's thoughts on Reagan and AIDS, it is important for backers and critics alike to remain in the realm of fact on the issue. For example, the oft-repeated canard that Reagan did not mention AIDS for seven years is just plain false. According to Carl Cannon, Reagan first mentioned AIDS in 1985, four years into his term. Furthermore, Bauer's role as the villain is overstated and inaccurate, given that he did not even become White House domestic-policy advisor until 1987. In addition, as early as 1983, HHS Secretary Margaret Heckler visited a dying AIDS victim in the hospital and held his hand, a gesture that demonstrated both compassion and made the point that the disease was not communicable through incidental contact.
The point is not that Reagan was some kind of far-sighted visionary in dealing with AIDS. Not even his strongest partisans would make that case. However, what we have seen in the evolution of government responses to public-health crises is the degree to which, as in so many other areas, expectations placed upon government have increased. Roosevelt advocated for polio research, to be sure, but he did not mobilize an entire government to fight the disease. He instead promoted private-sector charitable research. With respect to smoking, the government got involved slowly at first, perhaps too slowly, and was even tentative in the release of that first Surgeon General's report because of the possible impact it could have on the stock market. With AIDS, however, Reagan's critics denounced him for his apparent indifference, and for not spending enough, even though he did speak on the issue and allocated significant amounts of money toward combating the disease.
Another lesson is how public-health issues have become politicized over time. If FDR were alive today, it is possible, perhaps even likely, that polio advocates would criticize him for devoting insufficient government resources to the disease, and for failing to use his own paralysis to advance the cause of polio eradication. The attacks against Reagan on AIDS were a product of a far more political era, and should give pause to future presidents in dealing with the public-health crises of the future. Everything can and will be viewed through a political lens, and the expectations of government action will be far higher than they have been in the past. Studying history is usually a useful tool for dealing with a new phenomenon. In the world of public-health crises, however, the old playbooks clearly will not be sufficient to counter the critics and to meet the populace's mounting expectations.
OUR PUBLIC-HEALTH CRISIS
Obesity, America's most prevalent public-health crisis today, is the flip-side of what has until recently been seen as one of this country's great advantages. In the classic 1954 work People of Plenty, historian David Potter identified economic abundance as one of the essential characteristics of the American experiment. We now face a situation in which cheap and plentiful food, combined with the diminution of physical labor and the increase of passive forms of entertainment — TV, movies, computers, and video games — has led to an obesity epidemic. According to the CDC, "American society has become 'obesogenic,' characterized by environments that promote increased food intake, nonhealthful foods, and physical inactivity."
The American Heart Association reports that about one in three American kids and teenagers is overweight or obese, a rate that tripled from 1971 to 2011. As of 2014, the figure remains almost constant at 33.2%, according to the CDC.
While the causes of the epidemic are complex, the existence of the epidemic is undeniable. Over two-thirds of Americans are now considered overweight or obese, and this presents significant challenges to American policymakers. Given the relative novelty of the problem, we have little experience from previous legislators who have dealt with it. The experiences of FDR with polio, Kennedy with smoking, or Reagan with HIV/AIDS can provide some (but not enough) help to future presidents facing this new kind of crisis.
Although the obesity problem has certainly worsened in recent years, it has been imposing significant costs for a long time. According to a study by Anne Wolf and Graham Colditz, obesity costs amounted to $99.2 billion in 1995, of which $3.9 billion stemmed from lost productivity, reflecting 39.2 million lost days of work. Loss of productivity has become an even more acute problem since then. An analysis by Eric Finkelstein, Marco daCosta DiBonaventura, Somali Burgess, and Brent Hale estimated the cost of obesity among full-time employees to be $73.1 billion, which they found to be "roughly equivalent to the cost of hiring an additional 1.8 million workers per year at $42,000 each," about the average annual wages of U.S. workers.
Clearly, many individuals are willing to accept the personal and financial costs of obesity, and the U.S. political system may be willing to digest the economic costs of obesity. However, one frequently under-examined aspect of obesity is its impact on America's ability to shape world events and, more frighteningly, defend itself from harm. This was a concern raised in 2010 by Generals Hugh Shelton and the late John Shalikashvili when they asked, "Are we becoming a nation too fat to defend ourselves?" Shelton and Shalikashvili worried that the U.S. will have trouble finding future recruits for its all-volunteer military, especially since the Army found 27% of Americans in prime years for military recruitment — 17 to 24 — were "too overweight to serve in the military." In fact, they note, "being overweight or obese has become the leading medical reason recruits are rejected for military service," as the proportion of recruits who failed physicals due to their weight has risen by almost 70% since 1995. Add all of this up, they say, and "[o]besity rates threaten the overall health of America and the future strength of our military."
If there were ever a public-health crisis that called for a government-sponsored intervention, this would seem to be it. But despite the near-universal and bipartisan agreement that obesity is a problem, our presidents have thus far been unable to address the problem in a meaningful way, let alone begin to solve it. The reasons for this failure, as with the reasons for the underlying problem, are varied, but they do not diminish the need to find a workable public-policy solution.
We have in recent years seen presidents of both parties jump into this issue and try to use the bully pulpit to alleviate the situation. President George W. Bush not only led by example by maintaining excellent physical health, but he also directed HHS to start an obesity initiative and promoted healthy eating and exercise from the White House bully pulpit. The HHS initiative, led by Secretary Tommy Thompson, included a Food and Drug Administration report on the size and scope of the problem, and recommendations that included increasing evaluation and scrutiny of food labels, encouraging manufacturers and restaurateurs to provide more guidance, improving research on causes and fixes of obesity, updating FDA guidance on weight-control products, and improving messaging regarding obesity.
The Obama administration followed suit in this regard, and made combating obesity one of First Lady Michelle Obama's signature initiatives. In February of 2010, she launched "Let's Move!," a campaign designed to end obesity in a generation. Although she acknowledged that the goal was ambitious, she implicitly noted that previous efforts had not seen much success, telling USA Today that "We've got to stop citing statistics and wringing our hands and feeling guilty, and get going on this issue."
Although the "Let's Move" rhetoric may have been more ambitious than previous attempts to address obesity, the litany of familiar activities consisted of a "multifaceted campaign that will include more healthful food in schools, more accurate food labeling, better grocery stores in communities that don't have them, public service announcements and efforts to get children to be more active."
MENU OF OPTIONS
Given the challenges of coming up with anti-obesity proposals that are effective, not overly prescriptive, of manageable cost, and not divisive, policymakers face a relatively narrow band of options. As public-health experts Jeff Stier and Henry Miller write, "We are as concerned as anyone about obesity's effects on public health, but we believe that governmental, taxpayer-funded approaches to it should be evidence-based, cost-effective and non-authoritarian."
If the approaches taken thus far are unlikely to solve the obesity crisis (as seems to be the case), President Trump and his successors will have to come up with a new range of options. Having the president get the rhetoric right on obesity will be essential to ensuring that we can beat back this problem.
On the substantive side of things, Arizona has proposed an innovative approach that calls for an annual Medicaid surcharge for "obese people who don't follow a doctor-supervised slimming regimen." Unfortunately, this strategy will not promote positive health behaviors in all cases, especially among the very poor. Still, it makes sense that the government should begin to take at least a small step in the direction of incentive-based approaches.
Presidents have a great deal of power in the regulatory space, and they should use that power in the fight against obesity. These efforts should take place in arenas where the government has the most leverage — specifically, where the government is footing the bill. According to the Manhattan Institute's David Gratzer, two areas that come to mind are subsidized agribusiness and school nutrition programs, where the federal government spent a combined $19.3 billion in 2009. With respect to the $9.5 billion for agribusiness subsidies, a report that compared government subsidies of junk food and of fresh fruit found that junk food gets the better end of the bargain. The report found that, of the 37 ingredients that go into Twinkies, "at least 14 of them are made with federal subsidies, including corn syrup, high fructose corn syrup, corn starch, and vegetable shortening."
In addition, the federal government provides $9.8 billion for school lunches, giving the government significant leverage in determining the content of these lunches. Per Gratzer, we can take a bite out of obesity by cutting or reducing agribusiness subsidies to end the use of "taxpayer dollars to produce and market unhealthful foods," by imposing limitations on high-fat foods, and by issuing stricter food guidelines for government-subsidized school lunches. Indeed, as first lady, Michelle Obama championed the Healthy, Hunger-Free Kids Act, which set ambitious goals for better nutrition in schools, though those efforts have met with mixed results.
Some proposals have gone too far, however, threatening to destroy or prevent the development of consensus on how to address the obesity issue. One such proposal suggests that states put dangerously obese children into foster care to protect them from poor parenting. There has been at least one real-life example of this: In October 2011, a 200-pound Ohio third grader was placed into foster care, and a county spokeswoman cited "medical neglect" as the reason for the child's removal. National Review's Jonah Goldberg characterized his objection to the proposal as follows: "I don't trust these people. Once you establish the idea that the state can take away kids from loving parents because the state thinks they're not good parents, you really are off to the races."
The alternatives listed above may not go as far as some obesity experts would like. Taxing "bad" food, banning certain food additives or substances, or even placing obese children in foster care seem to be on the agenda of public-health experts. While these kinds of suggestions may make for interesting thought experiments, they are not realistic from a political or a commercial perspective. The fact remains that presidents of the future will have to face the obesity challenge in a world of constrained resources and sclerotic politics. Given this situation, future presidents should look to a series of less costly, more realistic policy recommendations in order to start turning back the tide of obesity. In addition to evaluating alternatives, though, presidents must have the will and the wherewithal to carry out these policies, regardless of political challenges.
THE INDIVIDUAL'S ROLE
Fighting obesity, or handling any public-health crisis, requires the use of a limited presidential playbook. Even if a president engages in the rhetorical, regulatory, research, and fiscal steps outlined above, so much of the work in fighting obesity, like all public-health crises to a greater or lesser degree, takes place at the individual level. Diet and exercise are, of course, the most important steps that an individual must take in this regard. So any first step at addressing obesity at the individual level must incorporate a healthy diet and regular exercise.
Beyond diet and exercise, individuals have a number of other options for combating obesity. Finding effective obesity treatments remains one of the biggest challenges to both the medical and scientific communities to date, and more options will increase the number of weapons available. The existing options for supplemental obesity intervention are primarily in three categories: pharmacological, surgical, and psychotherapeutic. All three employ relatively new methods or technologies, which demonstrates that one of the keys to solving the obesity puzzle will be humanity's continued ingenuity in finding technological solutions to knotty and contentious problems. At the same time, all of them involve real costs which must be borne by individuals, companies, the government, or a combination of the three.
Our obesity problem has serious consequences for our health, our economy, and our national security. These problems, already significant today, appear likely to worsen in the future unless we begin taking steps to stem the tide of obesity and work toward becoming a healthier, more fit society. Unfortunately, no president has yet initiated an effective anti-obesity strategy, and it does not appear likely that our new president will do so either. Furthermore, our perilous fiscal state, combined with our hyper-partisan and divisive political situation, creates severe limitations on the options available even for presidents interested in addressing obesity. For this reason, any realistic solution to our obesity problem needs to include a menu of reasonable, non-partisan, effective, and affordable alternatives.
For presidents, a workable approach calls for an appropriate level of rhetoric, better leveraging of existing government funding and subsidies to manage behavior on a large scale, and promotion of informed individual behaviors, as well as the use of effective individual therapies to help people cope with weight issues. No one of these strategies is a silver bullet that can solve our obesity problem. Taken together, however, a president can use them to follow in the footsteps of predecessors like Roosevelt, Kennedy, and Reagan who have taken on, and in some cases defeated, even more trying public-health challenges.
Tevi Troy is a presidential historian, former White House aide, and ex-Deputy Secretary of Health and Human Services. He is the author of Shall We Wake the President? Two Centuries of Disaster Management from the Oval Office (Lyons).
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