For years, regulation has been the strong armed tool of the government with regard to ensuring the public’s health. In their viewpoint piece in the September issue of JAMA, Dave Chokshi and Nicholas Stein lament the inherently politically charged nature of public health policy. This should come as no surprise. One only need recall the New York City “soda ban” debacle, with New Yorkers charging that Mayor Bloomberg was treating them like children. President Obama’s Prevention and Public Health Fund has been derided as a “liberal slush fund” by conservative opponents of the Affordable Care Act. The authors note that “public health regulation is often falsely portrayed as a choice between responsibility (of individuals) vs restriction (of freedom).” Certainly, public health regulation has often been seen as a form of “nanny state” control by the general population, but proponents argue that the government needs to play a central role in public health, citing to the progress made by regulations for tobacco control and nutritional interventions with regards to increased life expectancy.
Part of the problem is that public health interventions go largely unnoticed by the general public, and most individuals receive little direct benefit from most public health programs. Small, vocal groups and the occasional large powerful corporate interest tend to dominate the headlines in many public health debates. The failure of the New York City “soda ban” could easily fall under that category of discourse. The authors suggest that perhaps it’s time to reshape the politics surrounding public health.
One approach is to change the conversation. Rather than view public health regulation as the choice between individual responsibility versus restriction of freedom, public health advocates should sharpen their focus and argue that inaction is inherently a regulatory action, with the resulting public health outcomes as a direct consequence of that inaction. The authors cite the absence of workplace smoking bans as an active policy decision to expose employees carcinogens, thus increasing their risk for heart disease and lung cancer. Instead of constantly championing the liberal left, public health advocates should embrace common sense approaches from moderates and conservatives that may offer more broad appeal. Similarly, moderates and conservatives are much more likely to respond to appeals that are low cost or even revenue generating. As an example, Mayor Bloomberg may have had far greater success at taxing sugary beverages rather than imposing a ban on sodas. As revenue generating policies, taxation regulations on “unhealthy behaviors” often carry broad political appeal as a source of deficit reduction while simultaneously encouraging individuals to make healthier choices. These same policies can appeal to consumers who are increasingly indirectly paying for one another’s health choices, as taxing sugary beverages shifts the burden of payment onto those who continue to consume them.
Certainly, there is an important and legitimate debate about the role of the government and regulation in public health. That debate will continue ad nauseum, with an appropriate system of checks and balances both within government and the great public. But indeed the time has come to move that conversation away from individual responsibility and “nanny state” paranoia, from liberal versus conservative, toward a conversation about the consequences of inaction and the legitimate costs and benefits of any particular regulatory action.