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Free to be Foolish
Politics and Health Promotion in the United States and Great Britain
By Howard M. Leichter PRINCETON UNIVERSITY PRESS
Copyright © 1991 Princeton University Press
All rights reserved.
ISBN: 978-0-691-07867-0
CHAPTER 1
Foolishness and Politics
In 1808 a controversial but highly respected Scottish physician and professor of medicine at Edinburgh University, Dr. James Gregory, became involved in a debate over a parliamentary bill "To Prevent the Spreading of the Infection of the Small Pox." The bill would have prohibited vaccination within three miles of any city or town and required compulsory removal, isolation, and reporting of smallpox cases. The proposal met with considerable opposition, especially because of its compulsory provisions. Dr. Gregory, one of the bill's most vocal opponents, argued that "England is a free country and the freedom which every freeborn Englishman chiefly values is the freedom of doing what is foolish and wrong and going to the devil in his own way." The bill was soundly defeated.
One hundred seventy-five years later, on the other side of the Atlantic, a nationally syndicated columnist, James Kilpatrick, argued against another compulsory, putatively health-promoting public policy, a rule proposed by the National Highway Traffic Safety Administration to require the installation of air bags in all new automobiles sold in the United States. Kilpatrick insisted that the decision on air bags should be a function of consumer demand, not government regulation. According to the conservative columnist, "a free people must be free to be foolish."
Separated by nearly two centuries, thousands of miles, and vast technological changes, Dr. Gregory and Mr. Kilpatrick provided virtually identical answers to questions that historically have bedeviled pundits, policymakers, and the general public. Where does one draw the line between the power of the state to protect public health and the right of the people to make life-style choices? How much control should each of us have over decisions that may put ourselves, and perhaps others, at risk? Over the years, only the specific content of this debate has changed—compulsory vaccination against smallpox, or compulsory fluoridation; mandatory notification of tuberculosis cases, or of AIDS cases; safe milk, or safe sex; child nutrition laws or minimum drinking-age laws. Whatever its specific form, the essential issue remains the same: What is the appropriate role of the state in promoting responsible personal behavior? Periodically this issue has taken a prominent position on the political stage, as was the case in the decades just prior to and succeeding the turn of the last century and is the case today.
This book is about the current debate, and seemingly constant tension, over the role of government in two postindustrial democratic societies, the United States and Great Britain, in helping people secure both good health and personal freedom. I will argue that in recent years there has been a fundamental shift in the prevailing wisdom among opinion leaders and policymakers in both countries about the way people can best achieve healthy lives. The shift has resulted in increased emphasis on health promotion, especially through government-sponsored life-style modification, and decreased attention to securing access to health care. Over the past decade the political agendas of most postindustrial, democratic societies have been crowded with proposals to promote more responsible drinking, diet, driving, and sexual and substance-use behavior. These issues have transformed health politics from a largely consensual to a largely conflictual enterprise. This transformation results from the fact that health promotion policies differ significantly, in ways to be described below, from other areas of public policy and, indeed, other types of health policy.
Although health promotion issues play a prominent role in the personal lives and collective concerns of people in the United States and Great Britain, each nation has responded somewhat differently to the political and medical challenges posed by such public health problems as AIDS, tobacco and alcohol use, and motor-vehicle driving. A primary concern of this book, then, is to account for the similarities and differences in health promotion policy in the United States and Great Britain. I will suggest that despite common public health challenges, variations in cultural values and political structure have produced differences in the timing, tempo, and nature of the health policy response in each country.
A New Perspective on Health
It is difficult to conceive of anything more important or basic to human happiness, dignity, or freedom than good health. Over two thousand years ago the Greek physician Herophilos said, "When health is absent, wisdom cannot reveal itself, art cannot become manifest, strength cannot fight, wealth becomes useless and intelligence cannot be applied." Centuries later Ralph Waldo Emerson wrote, "Give me health and a day and I will make the pomp of emperors ridiculous."
The importance that people in the United States attach to sustaining good health is reflected in the billions of dollars we spend each year directly on health care—an estimated $590 billion in 1989, or $2,306 per person—and indirectly on things like vitamins, health foods, exercise, guides to health, and other paraphernalia, all in what one British observer has called America's "national preoccupation with health." A Gallup poll reported that among the goals most sought by Americans, the two most frequently cited were a good family life (82 percent) and good physical health (81 percent), while another study found that 42 percent of the respondents "think about their health more often than just about anything else, including love, work, and money."
Although Americans are by no means alone in the pursuit of good health, impressionistic and empirical evidence suggests that we may be more obsessive than most. For example, one study found that 97 percent of the people surveyed in the greater Cleveland area reported doing "something" (following a healthy diet, getting enough sleep, exercise, or relaxation, and so on) to maintain or improve their health. British researchers asked an identical question of a national sample and found that only 60 percent of their respondents reported similarly health-protective behavior. There are obvious sampling and cultural reasons why these two studies may not be entirely comparable, but the findings support anecdotal and descriptive data suggesting that the British are not as ardent in the pursuit of healthy life-styles as Americans. Nevertheless, the proliferation of health-food shops, fitness centers, and recreational magazines, along with the Thatcher Government's emphasis on personal responsibility, suggests that the gap may well close in the future.
In addition to the importance each of us places on good health, there is a special place assigned by democracies to the physical well-being of their citizens. Marvin Bressler calls this commitment one of our "master-values": "democratic societies are, by definition, committed to a series of ethical standards emphasizing the value of human life and well-being." It is not surprising that historic political leaders have conspicuously displayed their commitment to the public's health. Benjamin Disraeli once said that, "Public health is the foundation on which reposes the happiness of the people and the power of a country. The case of the public health is the first duty of a statesman." Clearly, then, good health plays a prominent role in both the individual and collective value systems of democracies such as the United States and Great Britain. All this is not to suggest that the whole point of living is to stay alive regardless of the sacrifice in personal pleasure or freedom. Skiers, mountain climbers, and smokers, to name a few, all make a trade-off between the statistical possibility of harm and the apparent certainty of pleasure derived from their activities. Having recognized this, I would return to my original point about the critical role of good health as a social ideal. To my knowledge there never has been any serious political debate over the desirability of being and staying healthy.
There has been considerable debate, however, over the question of how people and nations can best achieve what they so highly prize, and at what cost. There is, to begin with, the basic issue of the appropriate role of government in the area of health. Although it has long been accepted by people of all political persuasions that the state has some role in protecting the health of its people, there is less agreement over the precise nature and extent of that role. In terms of public policy, there are, in effect, four ways by which the state can help further the health of its people. It can support biomedical research; improve, guarantee, or subsidize access to health care; regulate environmental and product hazards; and encourage people, through education or regulation, to adopt more healthy life-styles.
For much of the last century or so, in both Britain and the United States, the prevailing wisdom has been that people may best maximize their prospects for good health through access to adequate health care. As a result, the emphasis in national debates on health policy has been on health care delivery. In this context, one major issue has been whether or not the state should help people secure access through a national health insurance system. Ultimately the British adopted a limited health insurance system in 1911 (it began operating in 1913), and then a comprehensive National Health Service (NHS) in 1948. In the United States it has been decided that only certain groups that are vulnerable (for example, the needy and the aged) or special (for example, veterans) should receive direct assistance from the state in getting health care, although many more people receive indirect assistance through tax deductions on private health insurance. Although there has been increased public funding of biomedical research in both countries over the years, in neither has this been an area of major state emphasis. In the United States, for example, government spending on biomedical research since the end of World War II generally has been around 2 percent of total national health expenditures.
In the past decade there has been an important shift in the debate over how people can maximize their chances of staying healthy. Since the mid-1970s, in most industrialized countries, greater emphasis has been placed on reducing environmental health hazards and encouraging more prudent life-styles. One of the earliest statements of policy support for this shift came in a 1974 Canadian government working paper, "A New Perspective on the Health of Canadians," by then minister of health and welfare, Marc Lalonde. The Lalonde report identified the major causes of morbidity and premature mortality in Canada (motor-vehicle accidents, ischemic heart disease, respiratory diseases, lung cancer, and suicide) and attributed them to self-imposed risks, that is, life-style, and environmental factors, including various forms of pollution. Thus, the Lalonde report placed life-style and the environment on a par with the more traditional concerns of health policy such as human biology and health care delivery.
The "new perspective" on health, as it came to be known, heralded a new era in which health care professionals, public policymakers, academics, and the general public have come to believe that greater progress toward our becoming a healthy people can be made through reducing both environmental hazards and self-indulgent, health-endangering personal behavior than in expanding access to health care.
Despite considerable scholarly concern with the validity and implications of the "new perspective" (see Chapter 3), few would challenge the assertion that an important shift has occurred in both the United States and Great Britain, in debates over health policy. Because of its national health system, Britain has continued to place considerable policy emphasis on health care delivery, but even there both Labor and Conservative governments since the 1970s have argued that prevention, especially through life-style modification, is the most cost-effective and medically efficacious way of improving the nation's health. In the United States, the shift at the policy-making level has been more pronounced, one crude measure of which is the virtual disappearance of the debate over national health insurance at the national level. For example, in 1970 and 1971 the Congressional Record lists a total of fifty references to national health insurance; between 1981 and 1988 there are three. Although there has been a recent revival of interest at the state level in guaranteeing access to health care for those without health insurance, the preponderance of public and private concern remains in promoting healthy behavior rather than expanding access. In both countries, policymakers and administrators have shifted their attention to such measures as mandatory seat-belt and minimum alcohol drinking-age laws, restrictions on the sale, promotion, and advertisement of tobacco and alcohol products, and distribution of free condoms and clean hypodermic needles, as well as various environmental health concerns. Health politics since the 1970s has been, to a considerable extent, the politics of health promotion and disease prevention.
Although environmental and life-style strategies are at the core of the current policy emphasis on health promotion, the two differ in their politics and political and social implications. Environmental policies tend to focus on collective, especially corporate, behavior such as industrial waste disposal, water, air, and noise pollution, and workplace hazards, while life-style policies seek to influence individual choice. The distinction between individual and collective behavior may not always hold, but it is an analytically useful one. This book will focus on those policies that seek to change individual, rather than corporate or collective, behavior; although in accomplishing the former (for example, reducing alcohol and tobacco consumption) they sometimes must do the latter (for example, requiring manufacturers to use health warning labels).
By excluding environmental and workplace health issues from this discussion, I am, of course, slighting a vital dimension of the overall health promotion agenda. The decision to do so was based on both tactical and analytical considerations. It seemed impractical to tackle, in a single volume, the full range of health promotion issues, especially since, as I argue below, life-style and health politics and policies differ significantly from those dealing with the environment or the workplace. In fact, and this is the more important reason for devoting my attention to life-style and health, these issues, more so than even environmental degradation or hazardous work conditions, have become politically emblematic of our time. Politically in the last decade, in both the United States and Britain, national administrations have sought to reduce the role of government in our lives and encourage greater self-reliance. In the area of health, this has meant shifting much of the responsibility for promoting health and the culpability for endangering it from the collective, both private and public, to the individual arena. This is not to suggest that environmental or occupational health problems have been ignored or that they are unimportant, but simply that the philosophical and political emphasis in the Thatcher and Reagan-Bush governments has been on individual rather than corporate actors.
Conterminous with the political shift from a collectivist to an individualist political orientation has been a change in the health consciousness of people in Britain and, especially, the United States. Beginning in the late 1970s in both countries, particularly among the younger, more affluent, and politically influential, the pursuit of good health through life-style change became a major personal preoccupation. In the United States, for example, the proportion of people indicating that they do something regularly to keep physically fit more than doubled between 1961 and 1984, from 24 to 59 percent of the population. In addition, the proportion of the population reporting that most prototypically health-pursuing behavior, namely jogging, increased over the same period from 6 to 18 percent.
In sum, both prevailing political sentiment and social habits reflected and inspired emphasis on the individual and the importance of personal responsibility. In this context life-style and health issues virtually became a symbol for our times.
Health Promotion, Politics and Personal Freedom
It is a central thesis of this book that public policies seeking to alter individual life-styles differ from policies on health-related environmental and workplace issues, and indeed other areas of health policy, in the nature of the politics and the range of policy alternatives they produce. Let me be more specific about this point.
(Continues...)
Excerpted from Free to be Foolish by Howard M. Leichter. Copyright © 1991 Princeton University Press. Excerpted by permission of PRINCETON UNIVERSITY PRESS.
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