In the United States, we place a high premium on freedom, and on the legal extension of that freedom—rights. It is telling that the Tea Party resistance to the agenda of Barack Obama, and the burgeoning progressive resistance to the Trump administration, while sharing little in common ideologically, are united by their reverence for rights, and by their concerns about losing them. In the case of the Tea Party, these rights notably include the right to bear arms, and the right to assemble and speak freely; on the left, the emphasis has been on issues like the right to safe reproductive care and pay equity, and the right of workers to unionize. Notably, all of these rights are rights “to”—this is to say, they represent our freedom to perform an action or access a resource that benefits us, and, in most but not all cases, enriches our civil society. But there is another kind of right—rights that are founded on the basis of freedom “from.” These include the right to live free from socioeconomic insecurity, or from the threat of environmental disaster, or the hazard of preventable injury and disease. Promoting freedom “from” is, in large part, the work of public health. In doing so, however, we sometimes find ourselves accused of paternalism, of infringing on the freedom “to” rights of others. With this tension in mind, a note on these two notions of freedom, and how public health can work to ultimately make freedom “from” just as integral to our society as freedom “to.”
What can our history teach us about our collective emphasis on freedom “to?” How did this emphasis evolve? Perhaps the most important record of American freedoms, the Bill of Rights, contains a number of famous freedoms “to.” They include the right to freedom of speech and assembly, to bear arms, to due process, to a speedy and public trial, and to a trial by jury. The remaining five amendments are either quite clearly freedoms “from” (freedom from unreasonable search and seizure, from having to quarter soldiers during times of war, from excessive bail and the infliction of cruel and unusual punishment) or, in the case of the Ninth and Tenth Amendments, relate to the Constitution itself. In addition to the freedoms “to” enumerated in the Bill of Rights—representing, as they do, the central privileges of being an American citizen—the Constitution has catalyzed our freedom “to” emphasis in another key way. Because the document was written at a time when many groups—notably African Americans and women—were excluded from the full scope of its protections, a central theme of American history has been the struggle of these groups to gain the freedoms that they were originally denied. The drama of this struggle has often revolved around freedoms “to”—to vote; to access the same lunch counters, schools, and public spaces as fellow citizens; or to marry. These achievements have become central to our country’s story, shaping the way we view ourselves and our freedoms, with freedom “to” arguably taking pride of place in the American psyche.
This freedom “to” emphasis has shaped our political reality in ways both positive and negative. The freedom “tos” codified in the Bill of Rights laid the groundwork for a free press, an open society, and a judicial system that, at its best, aspires toward an ideal of fairness. When we have fallen short of these ideals, the struggle for freedom—for civil rights, equal protection under the law, and a more equitable society where all can access the same rights regardless of race, gender, or sexual orientation—has done much to improve conditions, leading to decades of social and political progress. These efforts have also inspired the creation of influential civic organizations dedicated to safeguarding these hard-won rights and increasing the number of people who can enjoy them. Planned Parenthood, the American Civil Liberties Union, the National Association for the Advancement of Colored People, and the Southern Poverty Law Center are examples of such organizations. We have also seen how a freedom “to” emphasis can threaten the health and safety of citizens. The problem of gun violence is a case in point. In the centuries since the Second Amendment was written, the right to bear arms has, to a small but vocal minority of Americans, come to mean the right to unfettered firearm access at all times, in all places, to every kind of gun. The annual gun death toll in the US—more than 30,000 people per year—is a direct consequence of this interpretation, an interpretation promoted by powerful interest groups, notably the National Rifle Association, which have resisted efforts to curb gun violence. We have also seen pushback against everything from seatbelt laws, to portion controls for sugar-sweetened beverages, to indoor smoking bans. While all of these measures represent steps forward for public health, their implementation has been difficult in a society that tends to view freedom primarily in terms of what a person is empowered to do and to own.
What does the alternative view of freedom look like, i.e. freedom “from”? What does freedom “from” mean in the context of social and political systems? A key expression of this freedom can be found in the Universal Declaration of Human Rights. The Declaration states in its preamble that “freedom from fear and want has been proclaimed as the highest aspiration of the common people.” This is the core responsibility of public health, and the core challenge we face in all our work. In striving to achieve these goals, we often face resistance from those who are focused on freedom “to,” who see an aspiration towards freedom “from” as a threat to individual liberty. This happens when the institutions and policies that exist to safeguard the rights of populations to live free from the hazards of economic insecurity and disease are misconstrued as infringing on the rights of individuals. In 1789, the conservative political philosopher Edmund Burke addressed this issue in a letter, where he described what he saw as the best way of promoting liberty:
“The liberty I mean is social freedom. It is that state of things in which liberty is secured by the equality of restraint. A constitution of things in which the liberty of no one man, and no body of men, and no number of men, can find means to trespass on the liberty of any person, or any description of persons, in the society. This kind of liberty is, indeed, but another name for justice; ascertained by wise laws, and secured by well-constructed institutions.”
Burke’s support for shaping the legal and social institutions necessary to safeguard liberty is well captured by his phrase “the equality of restraint,” which suggests the role of these institutions in creating an environment where liberty can flourish. In making this case, Burke clarifies that these institutions are necessary to ensure that unfettered individual liberty does not trespass on the liberty of anyone else, and that such a trespass is, in fact, an injustice. To Burke, freedom from this encroachment—beyond the exercise of any single freedom “to”—is the essence of liberty; a powerful endorsement of the importance of freedom “from” to a healthy civil society.
Too often, what should ideally be a conversation about the social, economic, and environmental conditions that shape the health of populations becomes, instead, a debate over whether the work of public health is infringing on the rights of these populations. Such arguments generally pit us against a narrow, freedom “to” definition of rights; one which does not take into account how being able to live a healthy, productive life is not only a right in itself, but also a necessary condition for our capacity to enjoy other rights, not the least of which are our rights to life, liberty, and the pursuit of happiness. Rather than accept the terms of this debate, we need to change the context in which the conversation occurs, and appeal to our common constitutional inheritance, looking to it as the basis for many different kinds of freedom. This means making the case that both freedom “from” and freedom “to” are equally valid, essential characteristics of a society that prioritizes health and human rights for all populations, and bringing about a recalibration of our national conversation where freedom from disease—a healthy life—is a core aspirational freedom that needs to be afforded the same space in the national debate as freedoms “to.” Contemporary human rights doctrine summarizes the argument precisely: There is no hierarchy of human rights such that civil rights take precedence over economic and social rights; all human rights are interrelated and essential for human flourishing. That is in part our responsibility as a school of public health; to create the space for that conversation in our community—locally, nationally, and globally.
I hope everyone has a terrific week. Until next week.
Sandro Galea, MD, DrPH
Dean and Robert A. Knox Professor, Boston University School of Public Health
Acknowledgement: I am grateful to Professor George Annas and to Eric DelGizzo for their contributions to this Dean’s Note.
Previous Dean’s Notes are archived at: https://www.bu.edu/sph/tag/deans-note/