This book, completed a few days before the author's death, is both an understandably less well organized successor to his earlier (with James McCormick) Follies and Fallacies in Medicine (Tarragon, Chippenham, 1992) and another broadside in the Social Affairs Unit's campaign against what Dr Skrabanek chose to call coercive healthism. To understand what is meant by this expression it is helpful to recognize a distinction which he did not himself develop. At one time what were called public health policies were measures for the collective provision of what had good claims to be rated as public goods: Everyman's Dictionary of Economics actually gives "the anti-malarial treatment of still water" as one of its examples of such a good. But nowadays what are still called public health policies are, more often than not, collective measures designed to induce individual members of the public in question to behave in ways which, they are officially assured, will result in their living longer and healthier lives; with, in consequence, some eventual improvement in the national health statistics.

Coercive healthism is the state sponsored promotion of public health policies in this second understanding of that expression. Typically these policies involve what Dr Skrabanek called anticipatory medicine. Whereas

The important point about risk factors for multifactorial disorders is that they are not as such known to be causes which are bound eventually to result in those disorders. The risk factor for a particular disorder may be larger or smaller in different countries or at different times. Nor is it true to say: either that everyone incurring some particular risk factor will eventually suffer the corresponding disorder; or that everyone not incurring that risk factor will in consequence be spared suffering that disorder.

For instance: the best publicized of all such risk factors is the risk of dying of lung cancer - a risk incurred by heavy smokers of cigarettes. But in Greece that risk factor - a risk factor which, so far as I know, has never actually been calculated for Greece, certainly must be much smaller than it is for the UK since Greece, with the highest per capita cigarette consumption in the world, has a relatively low incidence of lung cancer. It is also true that even in the UK many lifelong heavy smokers, despite having already enjoyed more than the Biblical three score years and ten, nevertheless manage to die of something other than one of the diseases officially warranted to be "smoking related". Here Dr Skrabanek makes a characteristically mischievous reference to the International Journal of Epidemiology obituary of a well-known epidemiologist. It "pointed out that, though the dead man died of lung cancer, he was a non-smoker...an important piece of information. Death was not fair". [p. 69]

To libertarians it will seem self-evident that decisions whether or not to incur such risks are decisions which we all have a moral right to make for ourselves in the light of our own individual preference structures. "Since life itself", as Dr Skrabanek said in his earlier book, "is a universally fatal sexually transmitted disease, living it to the full demands a balance between reasonable and unreasonable risk". [p. 41] So all of us have to ask ourselves in every relevant case whether a perhaps not very great chance of some certainly modest increases in our several expectations of life are, to us, worth the price of making the officially prescribed changes in lifestyle. In making such decisions it is rational to recognize that the promised increases in life expectations are relatively small, and to remember that if we do not die sooner of one thing we shall certainly die later of another: two considerations which regularly seem to be overlooked in discussions of this sort of public health policy.

Because expectations of life in First World countries are now at worst only fractionally below or at best a year or two above the Biblical norm, even the most comprehensive and unlikely medical advances would make only a few months difference. Thus Dr de Fanu in Preventionitis: The Exaggerated Claims of Health Promotion (Social Affairs Unit, London, 1994) tells us that "it has been calculated that the rise in life expectancy for those between the ages of 15 and 65 from preventing or curing all cancers...would be only seven months". [p. 13] Since we are all mortal the benefits of not dying from this at time one need to be offset against the costs of dying from that at time two. Many of us, surely, would consider a reduced risk of an earlier death from a sudden heart attack much too dearly bought at the price of an increased risk of a later, protracted death from Alzheimer's disease? Indeed many of us, once having reviewed the prospects of the currently most common alternative deaths might wish greatly to increase our risks of eventually suffering fatal heart attacks.

The coercive healthists pay no respect to such individual preferences, however ration. Instead these political doctors, like the ruling Guardian class of Plato's Republic, go all out to induce everyone to adopt and to maintain whatever they as the anointed experts from time to time prescribe to be the uniquely healthy diet and the uniquely healthy lifestyle. Public health policies of this second, probabilistic, anticipatory sort are typically totalitarian. Thus in the Germany of the National Socialist German Workers Party "Gesundheit ist Pflicht (health is duty) was the dominant slogan". [p. 152]

Dr Skrabanek traces such ideas and ideals back, in the modern period to "Voyage en Icarie by Etienne Cabet (1788- 1856)...a follower of Babeuf....In Icaria, the ideal communist state, the doctor...was...salaried...and medical service was free for all....A healthy lifestyle was the key to the health of the nation. Intemperate drinking and eating, lack of exercise, sexual over-indulgence or tobacco smoking (about which Cabet had particularly strong feelings) were not tolerated. The goal of medical science was to prevent diseases from occurring". [pp. 153-4] Dr Skrabanek, who was Czech born but was driven to settle in Dublin by the tanks of "normalization" in 1968, comments that "Anyone who has lived in a communist country would find this premonition uncanny". [p. 154]

He goes on to suggest that "those who intend to introduce similar principles in Western democracies" should first study their actual effects in the former Communist countries: "What benefits, for example, have been observed in state-organized, compulsory cervical cancer screening programmes...?". [p. 154] Such screening programmes sound eminently sensible. But in fact they actually make sense only if and when some disease can be either prevented or treated earlier and hence more effectively; and that for tolerable costs not only financial but of all kinds.

It seems both that these conditions are in fact rarely met, and that there is a widespread reluctance to recognize that this is so. Thus, for instance, "according to the latest Swedish study, only one in 65,000 women offered mammography benefitted per year". [p. 35] Again, "the only British randomized controlled study of multiphasic screening... conducted...under the leadership of Professor Walter Holland, one of the most respected of British epidemiologists... showed no benefit in the screened group". [pp. 33-4: emphasis added] Yet this "study is not mentioned in textbooks on screening, in government publications or in relevant epidemiological articles. On the contrary, the Government uses financial incentives...to entice general practitioners into participation ...in health screening schemes". [p. 34]

Dr Skrabanek's general conclusion, supported by abundant evidence in both the present book and its predecessor, is that

Almost everyone actively involved in promoting "public health" policies in this new understanding of that expression is effectively misguided by what has now been usefully nicknamed the Lalonde Doctrine. This doctrine was openly advocated by Marc Lalonde, sometime Minister of National Health and Welfare in the Government of Canada, in A New Perspective on the Health of Canadians (Information Canada, Ottawa, 1974). Chapter 9, significantly entitled "Science versus Health Promotion

2, makes the crucial point clearly: "Science is full of `ifs', `buts' and `maybes' while messages designed to influence the public must be loud, clear and unequivocal". [p. 57]

Noting that scientists are divided on issues like the bearing of exercise and diet on coronary heart disease Mr Lalonde went on to insist that, such indeterminacy notwithstanding, "action has to be taken...even if all the scientific evidence is not in". [p. 57] Such, as Dr Skrabanek remarks, "is a familiar argument of consensus committees: if we don't know what to do, then let's do it with vigour". [p. 97] Mr Lalonde's conclusion is that

But now, if and when the available scientific evidence is thus insufficient and/or ambiguous in its implications, how can the politicians promoting their particular policies of behavioural modification nevertheless pretend themselves to know what the problems actually are and what are the right ways of solving those problems, in what directions; that is, whose behaviour has to be modified? Aficionados of the Lalonde Doctrine thereby become committed to making policy bets on behalf of and at the expense of a public from which they are at the same time committed to concealing the uncertainties of the betting issues. They are also inclined, as is indicated by the passage just quoted, to dispose of recalcitrants by simply assuming that all they have to offer in their defence is irrational rationalisation rather than objections deserving of serious discussion.

Public health policies of this new, second sort provide us with one more textbook example of how government, by attempting to do things which government ought not even to be attempting to do, becomes incompetent to do things which either government alone can do or which on occasion government can do better than any available alternative agent. For here we see government, which perhaps might usefully devote a little of our money to ensuring that everyone can have access to information which they need in making their own health decisions, instead preferring to suppress some relevant scientific findings while exaggerating the import of others in order to induce everyone to adopt and to maintain whatever is from time to time the officially approved lifestyle. (The qualification "from time to time" has to be made. For, although hostility to alcoholic drinks and tobacco products are apparently constants, there have been drastic reversals in dietary policies.)

Finally, a reviewer would be failing readers if he did not conclude by quoting the graffito which might have served as the motto for Dr Skrabanek's whole book: "I don't smoke or drink. I don't stay out late and don't sleep with girls. My diet is healthy and I take regular exercise. All this is going to change when I get out of prison". [p. 71]

Antony Flew