CARNETS DESCARTES

Public Health, Nanny State and Individual Liberty

(Version Française)

Public health policies are often perceived as threats against individual liberty. Actually, when they require to fasten safety belts when driving (and also for passengers), when they ban smoking (sin taxed) in restaurants, when they limit speed on motorways, implement incise taxes on alcohol and sodas, forbid alcohol when driving,.. all these policies reduce in a way or another our individual liberty. "All forms of puritanism has always been justified by the willingness to do the good" claimed some researchers (sociologists, policy scientists, economist) in a recent tribune in the French left wing journal Libération (article free of access, in French).

In the USA which are much more attached to individual responsibility and freedom than in our European culture, debate on these issues is raging. The NYC Mayor Michael Bloomberg recently lost when sued for his attempt to limiting the serving size of sweet sodas, to fight obesity."New Yorkers Need a Mayor, Not a Nanny" claimed one of his detractors, the Center for Consumer Freedom. Mayor Bloomberg was well known for his intervention against smoking tobacco, banning smoking in public places, including streets, parcs and beaches in NYC. To avoid such escalating approaches, Mississipi legislators have passed a law known as the "Anti-Bloomberg Bill", forbidding municipalities from regulating food and drinks.
We are facing here a central debate for the future of public health policies. Whatever from right or left wing (althouth public health regulation is often on the liberal end of the political spectrum, even if the French tribune in Libération shows that the terms of this debate is more complex), in low regulated countries such as the USA as well as in welfare states (e.g. Northern Europe), public health policies will face the dillemma of looking for the good of our citizens by limitating, sometimes heavily, individual freedom. 

In a recent viewpoint in the JAMA dated August 22, (free of access), Chokshi D (Departement of Veterans Affairs, Washington DC) and Stine N (New York City Health and Hospitals) ask clearly the point: "On the one hand, government policies approaches - taxes, bans, and other regulations - are emblematic of "nanny state" overreach [...] On the other hand, regulatory policy is described as a fundamental instrument for a "savvy state" to combat the conditions underlying an inexorable epidemic of chronic diseases". Chronic diseases account now as leading causes and burden of morbidity and mortality. Evidence strongly suggests today that agressive policies against smoking, alcohol misuse, obesity and sedentarity are tied to increases in life expectancy and longer healthy life years.

Chokshi and Stine suggest five avenues toward a realistic and durable political solution, I am trying to summarize here below:

1. Concertation and evidence based policies: to move from the debate which opposes those who defend individual freedom to those who seek for limiting them, let's show the public health consequences of inaction presented as a regulatory choice. For example, absence of ban on smoking in workplace would have consequences in terms of cancers and myocardial infarction in exposed employees. Authors ask for limiting interventions to those which are evidence based. They wish actions focused, targeted and more effective than reasonable alternatives, such as education campaign about large sodas).

2. Rediscovery of the political center in public health: Public Health advocates are often on the left wing, and must rediscover recommendations from moderates and conservatives. Authors provide a few examples, such as that from Arkansas which supports healthy food options in disadvantaged communities and schools, or in Oklahoma City driven by a Republican Mayor, which supports new recreational areas, public transportation and biking trails. Conservative countries such as Hungary or Romania have experimented with food taxes to promote healthier eating habits. Such approach may help seeking for consensus in societies.

3. Cost-effectiveness consideration: "thanks" to austerity, public health measures may by promoting health contribute to generate revenue. At least these measures are often at low cost. Transparency should be the rule regarding any intervention in public health.

4. Mobilisation of public opinion to support public health intiatives. The NYC Mayor elevated the priority of public health. Numerous private Foundations contribute to improve public health litteracy in public and decidors.

5. The human tendency to discount the value of future conditions by a factor that increases with the lenght of delay: authors suggest that physicians bear particular responsibility in addressing these problems, since they bear witness to regrets about prior unhealthy choices of their patients.  Physicians have also a special duty to weigh in on how society mitigates the social and environmental conditions that leads toward unhealthy choices.

Bureaucracy, moralism, hygienism, and sometimes eugenism are often mantra among public health decidors, from the whole political spectrum. That creates exasperation and anger to many citizens which refuse nanny state in their daily life. Lack of scientific evidence, lack of transparency, conflicts of interests in many decisions may geopardize trust and confidence in health authorities and their experts (such as ridiculous positions in many countries today with regards with electronic cigarettes). It is time now to place the citizen at the centre of these debates on health. It is time to increase democracy in decision making, and to open discussion which cannot anymore remain in the unique arena of experts.

 

Commentaires

  • Régis Deloche 23/08/2013

    Readers of this blog who think that “it is time now to place the citizen at the centre of these debates on health" are encouraged to read  “Considerations Concerning the Organization of Health Systems”, Report by Gilles Saint-Paul, http://www.cae.gouv.fr/Reflexions-sur-l-organisation-du-systeme-de-sante.html

    Christian de Boissieu, Former Chairman of the French Council of Economic Analysis,  Professor at the Paris I-Panthéon-Sorbonne University introduces this report by writing: “This report considers two aspects: What is the economic justification for state involvement in the health sector? What judgment should one give to the system where each medical act has a fixed tariff, and how can the system be improved?

    Here  is the summary of this report:“In this report, Gilles Saint-Paul gives his thoughts on the organization of the health system in France. As an economist working outside the health sector, he proposes a number of possible reforms for a sector of the economy with very specific characteristics. With a deliberately external view, he focuses his attention on two areas. First, the author asks what is it that can justify that health insurance and a part of health provision should be public and not private. Secondly, he explores the system of hospital financing by activity (T2A). This is a system whereby each act performed in a hospital has an associated tariff. This has the effect of an incentive for the hospitals to adjust their costs to the level of the tariffs imposed from the outside, but naturally raises the burning question of how these tariffs get fixed. Finally, the author reaffirms the validity of measures that help all the various stakeholders in the system (patients, doctors, health insurance firms) to take on board the costs. In particular the author recommends adopting a system of fixed-sum and ceiling index-linked on individual income.”

    Here is an excerpt from the letter of the FCEA summarizing this report: “The mandatory nature of health insurance is based in part on the notion that people are very short-sighted and sometimes do not see the point of insuring against serious illness if the chance of contracting such illness is very low. The state adopts a paternalistic attitude and decides to insure everyone.[…] As far as paternalism is concerned, the author suggests that mandatory subscription to a health insurance scheme, coupled with suitable publicity concerning risks, would overcome the problem of peoples’ short-sightedness”. http://www.cae.gouv.fr/IMG/pdf/CAE103_Resume_EN.pdf

    In addition, you are encouraged to read:

    http://www.reuters.com/article/2013/08/15/us-usa-healthcare-pennstate-idUSBRE97E19420130815?AllowView=VW8xUmo5Q21TcWJOb1gzb0tNN3RLZ0h0MWg5SVgra3NZRzROR3l0WWRMWEVWUFVlREMyVENBQzFuOVQ2K2lSRWZlRGxLaFEr

    and

    http://www.telegraph.co.uk/news/worldnews/australiaandthepacific/australia/9492504/Tasmania-considers-cigarette-ban-for-anyone-born-after-2000.html

     

  • Régis Deloche 26/08/2013

    Another comment about paternalism, health and economics:

    Being pregnant is a good deal like being a child again http://online.wsj.com/article/SB10001424127887323514404578652091268307904.html#project%3DSLIDESHOW08%26s%3DSB10001424127887324522504579002782221725194

    Modern pregnancy comes with a long list of strict rules, but does it have to? An economist examines the data and finds room for choice amid the familiar limits.

    Emily Oster (Associate Professor, University of Chicago Booth School of Business)

    http://faculty.chicagobooth.edu/emily.oster/

    debunks the myths of pregnancy using her particular mode of critical thinking: economics, the study of how we get what we want.

    Excerpt: “The key to good decision making is evaluating the available information—the data—and combining it with your own estimates of pluses and minuses. As an economist, I do this every day. It turns out, however, that this kind of training isn't really done much in medical schools. Medical school tends to focus much more, appropriately, on the mechanics of being a doctor.

    In reality, medical care during pregnancy seemed to be one long list of rules. Being pregnant was a good deal like being a child again.

    1)      You can only have two cups of coffee a day.

    2)      When I asked my doctor about drinking wine, she said that one or two glasses a week was "probably fine”.

    3)      Pregnant women are also given a long list of off-limit foods: deli meats, soft cheeses, and sushi.

    4)      Later in my pregnancy it felt like all of my time with my doctor was focused on how fat I was getting—so fat! I was supposed to gain between 25 to 35 pounds. At one visit it seemed like I was on track for 36 pounds, and I got a serious scolding.”

    What’s wrong with these recommendations? Are doctors working from bad data? Are they perpetuating false myths and raising unfounded concerns? Oster’s answer is "yes, and often".

    As concerns, for example, the first point, Oster writes the following: “Studies of the impact of caffeine on miscarriage have another problem: nausea. Nausea is a normal but unpleasant effect of pregnancy and a really good sign that it is going well. Women who experience nausea in early pregnancy are less likely to miscarry. My morning routine, when not pregnant, is to have a cup of coffee before breakfast on an empty stomach. Early in my pregnancy, this idea was, frankly, revolting. After talking with other women, it sounds like this is fairly typical. We know that nausea is a sign of a healthy pregnancy, but (as in my case) it also causes women to avoid coffee. This means that the pregnant women who drink a lot of coffee also are more likely to be the ones who aren't experiencing nausea. So here we may well be mistaking a correlation for an underlying cause: The women who drink less coffee have fewer problems not because they limit their caffeine intake but because they tend to suffer from nausea, which inhibits coffee drinking.” The key problem lies in separating correlation from causation.

    As concerns, for example, the last point, Oster writes the following: “Weight-gain guidelines are designed to maximize the chance that your baby is normal sized. If you gain less weight than recommended, you increase your chance of a small baby and decrease your chance of a large baby; vice versa if you gain more than recommended. There is a nice logic to this, but I quickly realized that very small babies are associated with many more—and more serious—complications than very large babies. The main concern with a very large baby is difficulty in delivery. Very small babies have an increased risk of breathing problems and neurological complications. […] In the end, I concluded that I should be more worried about gaining too little weight than too much.” The key problem lies in the focus only on the probability of each thing happening and not on the magnitude of the problem

    In addition, you are encouraged to read: http://www.amazon.com/Expecting-Better-Conventional-Pregnancy-Wrong/dp/1594204756/ref=zg_bs_4676_4/marginalrevol-20 "Expecting Better: Why the Conventional Pregnancy Wisdom is Wrong—and What You Really Need to Know”

     

Antoine Flahault's blog (in English)

Antoine Flahault's blog (in English)

Antoine Flahault's blog. He is Faculty member, in public health, from Descartes School of Medicine, Sorbonne Paris Cité

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