This week on TGH – regular blogger and NCDFREE change-maker Jo Jewell of the World Cancer Research Fund talks about health policy and its role in Global Health.
It has become abundantly clear over the decades that there are sometimes major issues adopting policies to prevent people from becoming ill through non-communicable diseases (NCDs). Starting with tobacco and now evident with alcohol, unhealthy diet and obesity, proposals for effective policy action – which centre on the need to reduce exposure to these risk factors – often fail to make it onto the agenda, are repeatedly blocked in government, or are challenged in the courts of law. While this is down to a combination of factors, accusations of ‘nanny state’ have been at the forefront acting as a barrier to government action.
It’s clear that the public cares a lot about health – the way in which governments choose to run our health care systems generates a lot of media coverage and is guaranteed to be a hot topic in the run up to any elections. Beyond health care, public health is often less visible, and the types of broader policies designed to influence public health appear to gain less immediate traction with the public. (Admittedly, public health can still hit the headlines and catch governments off guard, as is sometimes the case when the shocking extent of health inequalities within our countries is revealed). But it is when policies are perceived as being too interventionist, restrictive of choice or paternalistic that public health can really provoke headlines, controversy and debate (think ‘fat fascists’ or similar). At the forefront of opposition to these policies is the criticism that public health wants to ‘nanny’ the population – and, not wanting to risk public outcry, this can translate into a distinct lack of effective action by government.
An obstacle to progress
To illustrate the chilling effect this can have on policy, there are less than 5 countries worldwide with legislation or regulation on food marketing to children, and less than 10 using the price of food to improve health, despite the global epidemic of obesity. Similarly, plain packaging legislation in Australia is still being challenged in the courts, while David Cameron recently performed an outrageous u-turn on both plain packaging and minimum-pricing for alcohol. The insufficient implementation of effective policies globally is down to a combination of factors, but fear of nanny state is a core concern. We face these challenges in spite of the fact we have good evidence on what influences our behaviours and what policies are likely to be effective.
Why policy is critical
Let’s reflect on the fact that the overarching aim of NCD prevention policies is to empower and enable people to lead healthier lives. It will achieve this by targeting those factors that influence our behaviours (i.e. who eats/drinks/smokes what, when, where and how much). From the evidence, we know that factors in our immediate environments, such as the availability, affordability, and promotion of products, are a major component in influencing our behaviour. We also know that our behaviour is being intentionally altered by the actions of companies in a way that fundamentally shifts our demand for their products and encourages the development of unhealthy habits. For example, in the food arena, companies intentionally market products in such a way that it encourages us to consume more of them, more often, and they then manipulate the characteristics and price of the product to reinforce this effect.
It cannot (or, should not) be implied therefore that consumers are somehow only fulfilling their desires. Nor should it be suggested that the inevitable downstream health effects are simply an unfortunate consequence that must be tolerated because people ‘want’ to be obese or ‘want’ to become addicted to tobacco. Our choices and actions – which determine our health – are rarely made on a completely rational or informed basis but are in fact influenced in large part by our external environment, and in ways over which we may have little control. I don’t therefore buy the short-sighted, hands-off argument that people should be allowed do as they please and just be a little more responsible. I don’t believe it is as simple as that.
What this means is that we in fact need a whole suite of stronger policies to respond. These policies should target the factors in the environment that influence our behaviours, and the objectives of policies should be carefully designed to achieve maximum benefit. For example, we know that children’s dietary behaviours are influenced by marketing, and that the amount of exposure is critical in shaping their preferences and food choices. So well-designed policies that broadly protect children by reducing exposure to all forms of marketing of unhealthy foods and place tough rules on the manipulative content of the marketing are entirely justified.
Opponents (whether in government, with industry, or people politically/philosophically opposed to ‘big government’) attempt to undermine such public health efforts in any way possible. First they claim the policy measures are an unfair restriction of freedoms, then they pull apart the evidence. For example, the NYC supersize soda restrictions proposed by Mayor Bloomberg were portrayed as being an unfair and an unjust restriction of choice that ‘coerced’ consumers. In fact, people would still have been able to order as much soda as they wanted but the default was simply changed to make it more difficult. In order to further stall the policy, opponents also cast doubt on the evidence. So wrapped up in the whole ‘nanny state’ debate is a second criticism that the proposed policies won’t be effective anyway, because people will continue to ‘seek out’ unhealthy food and drink, alcohol or cigarettes.
Changing the narrative
When people say that these sorts of interventions are nanny state, I ask: do you want to go back to a time when you breathed smoke for the duration of transatlantic flights, or risked your life driving at night because the driver coming towards you was blind drunk?
Policies in these areas were once controversial, but have nowcome to be part of social norms and valued. My colleagues and I often reflect upon the fact that at some point in the future people will surely look back and think we were mad to ever let companies manipulate children through marketing junk food.
Through policy it will be possible to create new social norms over time, where people grow up valuing health and seek out opportunities to lead healthy lifestyles. But there is also an immediate task, which is to bring people with us on this journey – and the media needs to be a key ally, not an opponent, in promoting the benefits of public health policy. This way governments will have confidence that the public supports action. And, if they are then empowered to take a comprehensive approach, rather than piecemeal action here and there, we are much more likely to see impressive results over time.
I truly believe that accusations of ‘nanny state’ need to be re-examined. At its core this is a question about the role of the state and what the relationship between government, society and individuals should look like. This is by no means a new question and there has long been a debate in politics and philosophy around the ‘social contract’, legitimacy of state intervention, and what approach will produce the best outcomes for society.
When it comes to preventing NCDs, unnecessary deaths and disability, I feel that we – as a community – have a legitimate rationale to support intervention to protect and empower people. Particularly when it is so patently clear that industries with a completely different set of interests and motivations are allowed to interfere by influencing our behaviours. Very few public health policies have an ultimate aim of removing personal choice entirely – they are much more likely to focus on regulating the “worst excesses of manipulation” by private interests, changing the environment and cues so as to tip the balance from unhealthy to healthy. It is the duty of the state to protect the population and we all need to do a better job at communicating this so that people are better able to judge for themselves whether the government is actually taking away freedoms or simply trying to re-empower its citizens.
This article was commissioned by NCDFREE, in collaboration with Remedy Healthcare and Local Peoples.
Jo Jewell is the Policy and Public Affairs Manager at World Cancer Research Fund International, based in London. He has a background in European politics and has a Masters in Health Policy, Planning, and Financing. His experience mainly relates to food and alcohol policy, and his work has focused on advocacy at the European and global levels. He is a member of the Global Steering Committee for the Young Professionals Chronic Disease Network. His contributions to this blog represent his own views and opinions.