INDIANA UNIVERSITY, BLOOMINGTON

Ruth C. Engs, Resurgence of a New Clean Living" Movement in the United States. Journal of School Health. April 1991, Vol. 61, No. 4, 155-189.

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Resurgence of a New "Clean Living" Movement in the United States

Ruth C. Engs, Professor

Applied Health Science, Poplars 615, Indiana University Bloomington, Indiana 47405

ABSTRACT: During the late 19th century, a "clean living" movement emerged in the U.S. dominated by efforts to control alcohol consumption, tobacco use, and females' reproductive health. The movement also advocated proper diet, exercise and physical fitness, pure water, and moderation in caffeine and red meat consumption. Remarkably similar concerns have emerged again in contemporary American society. The current "movement" lacks central organization. Rather, it reflects a loosely related coalition of single-issue advocacy groups. Yet, the focus seems remarkably similar to the 19th century movement - legislative limitation of individual choice regarding personal health behavior, particularly with substance use and females' reproductive health. This article reviews the 19th century movement, describes aspects of the contemporary movement, and offers implications and recommendations for school health professionals. (J Sch Health. 1991;61(4):155-159)

"Those who do not understand history are doomed to repeat it." -- Santayana

Writer George Santayana's warning has never been more prophetic than when applied to the "hygienic" and social reform movement of the late 19th century viewed from today's perspective. Health professionals need to know about a new social reform movement attempting to exert legislative control over individual preferences in several health and lifestyle areas. The current cycle has led to legal restrictions of lifestyle choices for some Americans and curtailment of what may be taught in some curricular areas. The movement could further prevent health educators from discussing certain topics, prevent school nurses from appropriate referral and counseling, and prevent Americans from making personal choices concerning health and lifestyle issues.

This article highlights negative aspects of the current trend, particularly in regard to abridgment of personal choice. Some positive effects of the movement during the past few years resulted from lifestyle changes through education - not social legislation.(1) However, with the "swing of the pendulum" of this cycle, negative aspects could outweigh the positive. A delicate balance must be maintained between social legislation and personal choice as trends sometimes get out of control, resulting in harm to the individual and to society.

THE 19TH CENTURY "CLEAN LIVING" MOVEMENT

Anti-alcohol and cigarette lobbying and a law mandating state control over women's reproductive choices dominated the late 19th century. Other activities included a health and fitness campaign that advocated a diet rich in whole grain products, exercise, self-help books, filtered water, and warnings about the danger of heavy caffeine and red meat consumption. These same issues dominate the news today. The issues influence debate and funding within the scientific community, the U.S. Congress, and the federal judiciary. The waxing and waning focus on these issues appear to be cyclical.(2) In the 19th century, the clean living crusade emphasized temperance (anti-alcohol and tobacco) and anti-pornography including birth control information and devices. Reformers claimed eliminating the evils of alcohol, tobacco, and pornography would return traditional family values and lead to a prosperous Golden Era free from crime.(3)

The 1873 federal Comstock law made it illegal to mail birth control information and devices. This law prevented women from having free access to techniques, methods, and items enabling them to regulate the frequency and number of pregnancies. In 1914, Margaret Sanger, concerned about unwanted pregnancies which often resulted in premature death among poor women, began to distribute birth control information and devices. She was arrested and jailed many times while challenging this restrictive law on women's reproductive choices.4 Reflecting the general repressiveness of the time, six years later the 18th amendment was passed, making it illegal to manufacture or sell alcoholic beverages and eliminating the choice to consume alcohol legally.

However, these prohibitions did not lead to a Golden Era. Instead, they produced an uncontrollable and untaxable black market economy, increased crime, and deaths of thousands f women from ensuing health complications of unwanted pregnancies.3,4 These serious social problems finally led to changes. Birth control

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devices were allowed to be sold to prevent disease in the 1920s, and the Comstock laws were eliminated in most states by the late 1930s.4 Prohibition of the manufacture, sale, and distribution of alcoholic beverages was repealed in 1933. Lifting these repressive laws enabled the individual, and not the state, to make choices concerning alcohol and sexuality.

CONTEMPORARY HEALTH AND FITNESS MOVEMENT

Similar to the 19th century clean living movement, the 1980s witnessed an increased concern about health and fitness with emphasis on exercise, reduction of fat, red meat, and cholesterol in the diet, consumption of whole grain cereals, stress reduction, and other aspects of a healthy lifestyle. However, it also included a growing crusade against alcohol, tobacco, sexuality education, pregnancy control, and health care choices.

The contemporary "movement" is not an organized whole. It is a sum of various single-issue topics associated with community and national groups. Many, but not all, have as their agenda legislative limitation of individual choice in various health and lifestyle issues. Examples include Right to Life, which advocates legislation to eliminate choice concerning pregnancy termination, Citizens Against Tobacco, which lobbied for federal legislation to ban smoking on virtually all domestic airline flights, and Concerned Parents for Children's Education,5 which advocates abolishment of all sexuality, alcohol, and drug education in local schools.

An underlying theme for special interest groups suggests individuals cannot be trusted to make health and lifestyle choices, or that the person is making the "wrong" health choice. Therefore, to protect people from themselves or to protect society, the state should pass legislation that enforces restrictions likely to promote health by taking away the individual's personal choice. This process also includes taking away personal choice of health educators or school nurses from discussing all sides of health issues or offering students choices in health care in some school districts.

Though the current social reform trend has received little attention in the professional literature, Engs and Fors6 labeled one of its aspects as "drug abuse hysteria." Heath,7 Blocker,2 and Pittman8 described it as the "new temperance" and "neo-prohibition" movements. However, some aspects hve been noted by the mass media. It has been labeled the "new Victorianism,"7 "neo-Puritanism," 9 "the new Sobriety,"10 "the anti-smoking movment,"11 and the resurgence of McCarthyism.12 However, these different aspects form parts of the same trend with an underlying agenda of fostering social control through legislation as opposed to individual choice.

Though the thrust of the movement, as pointed out by these authors, focuses on alcohol, tobacco, and sexuality, prevention of individual choice in other areas also has occurred. The state of Missouri prevented the Cruzan family from discontinuing artificial life support to let their brain-damaged daughter die with dignity. When state restricts were overturned, Operation Rescue attempted to block the family from making this difficult personal decision.13 In individual choice concerning health care options, the state of Connecticut forced a child to have surgery rather than allow the parents the alternative of obtaining traditional Chinese medicine for treatment.14 Currently, the greatest area of advocacy and legislation for social control, as opposed to individual choice, concerns alcohol, as was true of the late 19th century movement.

ALCOHOL AND TOBACCO ISSUES

Many advocacy groups, such as the Center for Science in the Public Interest, National Council on Alcoholism and Drug Dependency, and National Coalition for the Prevention of Impaired Driving, attempted to foster legislation to limit alcohol consumption during the 1980s. Such groups advocate "social control of availability," sometimes referred to as "control of consumption" model.8,15,16 This model suggests drinking-related problems and alcohol consumption can be reduced by legislation such as prohibition of drinking among youth, higher federal taxes on alcoholic beverages, elimination of electronic media and college campus advertising, warnings about the dangers of alcohol on beverage containers and in advertisements, limiting retail outlets, and more restrictive hours for alcohol purchase.

Other alcohol advocacy groups focus on drunk and drugged drivers. Mothers Against Drunk Driving and Remove Intoxicated Drivers promote stricter legal penalties for intoxicated drivers and drinking prohibition for youth. furthermore, as part of this trend, some authors suggest Prohibition was successful and imply that alcohol again should be eliminated from the U.S. to reduce crime, violence, and homicide(17,18). Consequences from the anti-alcohol aspects of this movement has resulted in federal and state legislation since the mid-1980s. New laws include the 1987 national prohibition for purchase of alcohol beverages for those younger than age 21, a federal tax increase on alcoholic beverages in 1991, and more stringent state laws against driving while intoxicated.

In addition to alcohol, anti-tobacco groups such as Citizens Against tobacco, Action on Smoking, and the Coalition on Smoking or Health advocate legislation to control smoking behavior. These groups have actively fostered federal legislation to ban smoking in airplanes and public places, eliminate all tobacco advertisement, and increase tobacco taxes. Due largely to efforts by these groups, federal legislation has eliminated smoking on most domestic airline flights and increased federal taxes on cigarettes. Communities such as San Luis Obispo, California, have adopted smoking bans in all businesses. Today, many community groups are attempting to prohibit smoking in public areas including malls, restaurants, and public buildings.11

However, controversy surrounds the effectiveness of laws based on the control of consumption model. Supporters15,19,20 claim it effectively reduces alcohol abuse problems among all age groups. However, some researchers suggest scant evidence supports effectiveness of the model particularly in a pluralistic society such as the U.S.8,21,22 Chafetz23 and Heath22 imply research supporting the model may even be a distortion of science for political agendas.

Evidence suggests some legislation resulting from

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the anti-alcohol aspect of the movement has not been effective at least among college youth. No change has occurred in the percentage of students exhibiting alcohol abuse behavior other than a continuing trend, which began in 1981-1982, of decreased drinking and driving related activities.24 Furthermore, after passage of the 21-year-old purchase law, a higher percentage of underage, as opposed to legal-age, students exhibited alcohol abuse or risky drinking behavior.25

Moreover, Heath26 noted that not until after alcohol and illicit drug use reached a peak in 1980-1981, and was in decline,27 did a dramatic increase in concern and massive funding for educational programs or legislation occur28 to cope with a perceived, but not actual, growing problem. The exception was tobacco education which has been a concern since the mid-1960s.

Perhaps more importantly, the current movement has overshadowed health educators' recommendations for objective and comprehensive school health programs. For example, some teachers have lost the choice of what to teach concerning alcohol and drinking. Abstinence is the only educational philosophy advocated by the prevention branch of the federal government in regard to young adults.29 Guidelines from the U.S. Office of Substance Abuse Prevention (OSAP) discussing what can be taught in the classroom are anti-alcohol. Safe, responsible, or "low risk" drinking cannot be presented by schools or teachers who receive funds from this federally sponsored program.

In addition, educational materials for those who choose to drink, which describes moderate practices, are difficult to find. For example, the booklet Drinking Etiquette, which outlines responsible drinking manners and behavior, was distributed by the federal government in the 1970s. It stopped being published in the 1980s when most federal public educational material adopted an abstinence orientation. Today, material that describes low-risk and responsible drinking for those who choose to consume alcoholic beverages is difficult to find.

Restrictive federal OSAP guidelines to alcohol education limit the choice of what health educators may teach and prevents students from obtaining unbiased comprehensive information. Adolescents need a choice of objective education programs, and some evidence suggests they can be effective in preventing abuse. Fors30 described several school-based curricula aimed at preventing substance abuse that have reduced problems. Also, Students Against Drunk Driving advocates personal empowerment by encouraging high school and college students to sign a contract to have a nondrinking person drive them home if they or their driver have been drinking. Finally, Milgram31 discusses philosophical issues concerning alcohol/drugs integral to a comprehensive education program that enable students to make individual choices as opposed to legislation which attempts to control their behavior.

SEXUALITY ISSUES

As was true in the 19th century clean living movement, the second major thrust of the current trend advocates legislative control over individual choice concerning reproductive health care. Several groups have attempted to block not only reproductive health care options but comprehensive school-based sexuality education programs. The primary aim of these groups, as with the alcohol-oriented groups, is to take away individual choice through legislation. For example, the National Right to Life Committee advocates legislation to eliminate a woman's choice concerning elective pregnancy termination. They have exerted pressure on the judicial and congressional branches of government to either overturn existing laws or pass new legislation severely restricting this personal choice, a position also supported by the executive branch.

Other examples reflect government restriction of health care options that prevent women and health care providers from individual choice. The French developed the anti-implantation drug RU496,32 however, pressure from anti-choice advocacy groups has impeded testing of the drug in the U.S. Drug companies also have been reticent to test and manufacture the drug because of boycott threats by these groups.33 Though it has been available for several years in France, American women are not allowed this option nor are their physicians given the choice of prescribing this medication.

Attempted federal control over health care information and options was mandated in Title X of the Public Health Service Act of 1988. Until this latest revision of the act, all health care options, including pregnancy termination, could be discussed with patients attending clinics funded by the program. This revision attempts to prevent clinics from discussing, counseling, or referring patients for abortion. This potentially restrictive act is being challenged in the U.S. Supreme Court.34 On the local level, anti-birth control groups have attempted to block teen-agers and adults from obtaining contraceptive methods and information.35

A dramatic decline in abortion-related maternal deaths and injuries occurred since women were allowed the choice of safe and legal pregnancy termination.36 Yet, as the maternal death rate decreased, an ironical increase occurred in national efforts to eliminate a woman's right to legal pregnancy termination.

Important to school health personnel is advocacy by national and local groups to eliminate school-based health clinics and to prevent comprehensive sexuality education.37 In Albuquerque, N.M., a school health clinic offering general health care services was attacked because of this fear even when it was not dispensing contraception.28 In some school clinics, condoms are distributed with parental consent to sexually active youngsters.39 However, in some communities opposition to this option exists and distribution of condoms to sexually active youngsters has been prevented or eliminated.

Furthermore, the movement exerts pressure to either eliminate sexuality education from schools or allow only abstinence-oriented curricula. One such curriculum, Sex Respect40 is being pilot-tested with federal funding; another is "Teen Aid" - Sexuality, Commitment, and Family.41 Both consider abstinence as the only choice outside of marriage. These curricula discourage students' options for choice made on objective materials and hinder teachers from discussing unbiased factual information.

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In the sexuality area, as with alcohol and drugs, comprehensive education is advocated. Education programs have been credited with decreasing HIV and other STD infections among male homosexuals as they adopted safer sexual behaviors during the past decade.(42) Both SIECUS (43) and Planned Parenthood, founded by Margaret Sanger during the last anti-reproductive choice movement, recommend comprehensive sexuality education appropriate for different age groups in schools. The Centers for Disease Control suggests "junior and senior high school students should receive accurate, timely education about sexually transmitted diseases."(42) One curriculum considered balanced in its approach to sexuality is Human Sexuality: Values and Choices,(44) which advocates sexual abstinence for young teens but provides accurate information concerning contraception.

IMPLICATIONS FOR SCHOOL HEALTH PERSONNEL

This new "clean living" movement poses serious social and educational consequences. This type of movement occurred before and led to laws that prevented not only teen-agers but adult women from having pregnancy control information or health care choices resulting in needless deaths from consequences of unwanted pregnancies. It led to a Constitutional amendment taking away the choice to legally consume alcoholic beverages which, in turn, resulted in illness and death from illicitly manufactured beverages, caused an untaxable black market, and increased crime and social problems.

School health professionals often feel caught in the middle of community battles on eliminating individual choice and information. Many educators feel abstinence represents the best choice for youth concerning sexuality and alcohol consumption until they have the maturity to responsibly engage in these behaviors. However, educators working with youth realize that most high school and college students engage in these activities. Between 27% and 70%45 of high school students are sexually active and 10% become pregnant.46 The U.S. has the highest teen pregnancy rate in the industrialized world,47 and AIDS is increasing among heterosexual teen-agers.48 Almost 70% of teens drink at least once a month,27 and 24% of under-age college students are heavy abusive drinkers.25

Despite these statistics, some school personnel are not allowed to discuss, much less demonstrate, techniques for low-risk and responsible drinking or sexuality. School health personnel may not be allowed to counsel or to dispense contraceptive information and devices to sexually active youth. They may not be allowed to refer teens for pregnancy termination counseling. These restrictions eliminate choices for professionals and students.

RECOMMENDATIONS

Historically, the abstinence approach rarely has worked, particularly in alcohol use and sexuality issues. Both in terms of legislation, which has legally attempted to take away personal choice, and educational programs.(49,50) Therefore, youth should receive accurate unbiased information and techniques to guide them in making safe, low-risk, responsible decisions concerning these health and lifestyle areas. Comprehensive school health programs give youth a "solid foundation of health information and lifetime skills."(51) As part of comprehensive programming, students need to be taught self-responsibility.(52) A full range of medical care services to increase access for youth in school health services must be assured,(53) and appropriate health care referrals must be made.

School health professionals must be aware that health issues have moral, religious, political, economic, and scientific considerations in a pluralistic society. No consensus exists as to the best approach or to "right" and "wrong" behavior in these areas. Therefore, in developing curricula and programs, all aspects of these issues should be discussed and material should be balanced. In discussions of health issues with religious or moral overtones, adolescents should be encouraged to follow the values of their families. Furthermore, school health professionals should become actively involved in communities to ensure that all points of view concerning controversial issues are included in the program.

Finally, as citizens of a pluralistic society that proclaims freedom of expression and choice, the right of all citizens to unbiased health information and medical care options must be protected. Legislation that attempts to prohibit health care alternatives and lifestyle choices must be approached cautiously. Individuals must be allowed to make personal decisions about their health, even if it differs from our own personal value systems and beliefs.

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