Good for the World…Good for Me?
Before beginning today’s note, an acknowledgement of the growing humanitarian crisis in Puerto Rico in the wake of Hurricane Maria. Our thoughts are with the Puerto Rican members of our school community, and with friends and colleagues in the region. It has been disheartening to see how slowly relief efforts have come together at the federal level—hopefully these efforts will gain momentum in the coming days and weeks, and we will start to see more progress on the ground. Yet as important as a well-coordinated response is when disasters strike, we in public health know that it is the social, economic, and environmental well-being of a society that makes the critical difference after events like hurricanes. I have written previously about how existing conditions like poverty and poor infrastructure can shape the long-term consequences of disasters. May the present crisis serve as a chance to improve these conditions in Puerto Rico, so that the island can emerge from this tragedy stronger.
For today’s note, a look at some of the challenges to improving these conditions, and how public health might work to overcome them.
Health is, generally, a cherished value. At the same time, public health often runs into resistance to efforts that would, on one hand, improve the health of populations, yet also seem to run counter to our wish to maximize our range of personal choice. This comes up time and again when a measure designed to improve the health of populations strikes the individual as an imposition, creating pushback against progress. Think, for example, about resistance to motorcycle helmet laws, or to efforts to restrict the sale of extra-large portions of sugary sodas. Why do we see this resistance? I think, at core, some efforts that could improve the health of the public are viewed as perhaps good for the world yet not “good for me.” This perception introduces an opportunity for particular interests to mount efforts to resist the intended public health action. It seems therefore to behoove us to try to understand why some issues may be seen as such an imposition, and to mull how we may navigate these two sometimes opposing, sometimes overlapping imperatives—perceived personal interest and the broader goals of public health.
At the top right of the grid are measures that could substantially improve the health of populations, yet are also likely to be viewed as an imposition by individuals. At the bottom left of the grid are measures that are less easily characterized as a burden to the individual, and whose population health benefit is minor. In between are measures that pose maximum benefit to population health with minimal imposition on individuals, and measures that pose minimal population heath benefit with maximum imposition on individuals.
Four examples illustrate these categories. In the top right corner are taxes on alcohol and cigarettes, sometimes called “sin taxes.” Raising cigarette prices through taxation represents a powerful means of reducing tobacco consumption, especially among high-risk populations. Alcohol taxes have been shown to produce similar reductions, not just in consumption, but in related harms such as drunk driving. Both measures, however, have also been criticized for interfering with individual choice through regressive taxation, and for being paternalistic.
On the opposite end of the grid are warning labels. Few could mistake warning labels for being coercive. They are simply “nudges,” conveying information about a given substance in the hope that individuals will choose to avoid unhealthy consumption. They also tend to be ineffective, providing little population health benefit.
Nearer to the “more population health benefit” axis is childhood vaccination. As I have written previously, the population health gains of widespread vaccination are among the sentinel triumphs of public health. Vaccination has led to steep declines in infectious disease morbidity, including dramatic reductions in measles and the elimination of wild-type polio from the Western Hemisphere. Globally, vaccines are responsible for saving an estimated 2 million to 3 million lives each year. These critical advances have been made with minimal burden placed on individuals. Despite the voices of the anti-vaccine movement, the vast majority of people in the US continue to choose for their children the simple administration and proven health benefits of vaccination over the distortions and bad science of its detractors.
Finally, there is the promotion of diet and exercise lifestyle modification programs to improve health. I have often addressed the inadequacy of lifestyle modification as a public health strategy. In addition to the difficulty of getting people to change their behavior, lifestyle modification is, definitionally, a fairly substantial imposition on the individual. Given all that is involved when someone makes a wholesale change in her habits and routines, and the challenge of inspiring such change at the population level, investment in lifestyle modification is not an effective path forward for the work of public health.
The intent in this simplifying categorization is to give us a lens through which we can consider public heath efforts. With that in hand, why do we view certain measures as more of an imposition than others? I would argue that there are two reasons. First, most obviously, such measures—like “sin taxes”—seem to limit what we can buy and do. In the US, this limitation, whether real or imagined, runs counter to our cherished emphasis on individual freedom. Yet, as I have argued before, there is another kind of freedom that this emphasis threatens to overshadow: our collective freedom to live a healthy life. We have overwhelmingly identified the “liberty” aspired to in the Declaration of Independence as the province of the individual’s capacity to make her own choices. But we have forgotten that this liberty is framed in the context of “life…and the pursuit of happiness”—two conditions for which health is a prerequisite. It is the task of public health to shift our emphasis, so that the freedom to be well is just as highly valued in the US as the freedom to buy and do what we wish. Second, measures like sin taxes appear burdensome to many because the individual is liable to feel the unwelcome personal effects of these measures long before she sees them begin to shape health for the better. For example, before exercise can make a better body, the individual must sweat and ache; before sin taxes can make healthier populations, the individual must go without alcohol and cigarettes. With less intrusive measures, such as vaccination and warning labels, personal inconvenience is either nonexistent (warning labels) or momentary (vaccination). In the case of vaccination, the population health effects are immediate and lasting, with no time-lag between the introduction of the measure and its benefits. This is why it is in a stronger position on the grid.
Can attitudes towards seemingly burdensome health measures be changed—can we move issues on the grid? History suggests we can. The example of vaccination is instructive here. From the beginning, vaccines were regarded with skepticism, viewed as potentially ineffective, or, worse, as dangerous. During this early period, they could have been placed in the upper right-hand box of the grid. Yet perception shifted, as the public began to see that the proven benefits of immunization far outweigh any personal inconvenience. Through the years, this understanding has been reinforced by the fact of herd immunity, whereby the choice of individuals to vaccinate their children helps to create a shield against disease that is greater than the sum of its parts. In this way, the act of vaccination has come to inspire individual buy-in not because of self-interest alone, but also as a willing contribution to the public good.
This provides a lesson for other areas where we seek to shift public opinion towards accepting measures that benefit the many, even if such measures are inconvenient for the individual. Rather than attempting to convince people that what they regard as a burden is not really as bad as they think, we need to revitalize the idea of public health as a public good. By working towards a culture that values our collective investment in health, we can build a world where individuals do not shy away from health solutions that are not always entirely cost-free, aiming for a society that esteems the wellbeing of populations as much as it does the autonomy of the individual.
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 Eric DelGizzo for his contributions to this Dean’s Note.
Previous Dean’s Notes are archived at: http://www.bu.edu/sph/tag/deans-note/