By Thomas R. Frieden, M.D., M.P.H., Center for Disease Control
N Engl J Med 2013; 368:1857-1859 May 16, 2013DOI: 10.1056/NEJMp1303819
What is the appropriate role of governmental public health action? Law and public opinion recognize protection of health and safety as a core government function, but public health actions are sometimes characterized as inappropriately intrusive. Such criticism has a long history, but today we accept many public health measures that were once considered misguided, intrusive, or controversial. Public health initiatives include efforts to promote free and open information to facilitate informed decision making, protect individuals from being harmed by other individuals and groups, and facilitate societal action to promote and protect health (see table ).
Free and open information empowers people to make informed choices and reduces the likelihood that misinformation or hidden information will endanger health. Laws may require disclosure of factual information (e.g., product content), provide for government transparency (freedom of information), or prevent dissemination of inaccurate or misleading information. Newer applications of this principle include calorie labeling in restaurants, which appears to encourage some companies to offer and some people to choose more healthful food options.1 The initial costs to restaurants to perform nutritional analyses and reprint menus and menu boards are the focus of most objections, but these costs may be counterbalanced by lower health care costs and increased productivity. Some people value the transparency that such laws require, regardless of the health effects.
Another example of the power of information is the graphic warnings on tobacco packages and antitobacco advertising to encourage smoking cessation.2 Pack warnings convey clear information about the health effects of tobacco use, creating a visual and visceral counter to the aggressive and often misleading information spread by tobacco companies, which have been convicted of deliberately deceiving the public about the health effects of tobacco. Antitobacco advertising helps counteract the industry’s efforts to undermine science and its massive marketing expenditures. Opposition to such government efforts may have financial as well as philosophical or legal bases.
A second key role of government is to protect individuals from preventable harm caused by other individuals or groups. An individual’s right to engage in particular conduct may affect others (“your right to swing your fist ends at my nose”). Government has a responsibility to protect individuals from unhealthy environments, whether the sources of health risks are natural (e.g., mosquito infestation) or created by people or organizations. Few Americans now question government’s role in preventing sales of contaminated food, water, and medications; reducing alcohol-impaired driving; or protecting workers and communities from industrial toxins.
For some issues, government may be the only entity capable of promoting the greater good by reconciling social and economic interests. Limiting promotion of tobacco and alcohol helps individuals by reducing consumption and benefits business by increasing workforce productivity and reducing health care costs. Although increased use of their products benefits tobacco and alcohol companies’ employees and shareholders, other companies and society bear increased medical, economic, and social costs, as well as the illness and deaths caused by use of these products.
Opinions vary about whether a given behavior’s risk to others is sufficient to warrant governmental action. But where there are clear ways to prevent substantial harms, government may have a responsibility to act. Smokefree laws illustrate the growing acceptance of actions that protect people from others’ behavior. Such laws are often controversial when introduced, with opponents predicting reduced hospitality-industry profits and decrying infringement of personal freedoms, but they gain acceptance as people see their health benefits — and no economic harm to businesses. Smoke-free laws cost little to implement, improve health, reduce health care costs, increase productivity, save lives, and do not reduce overall business revenues or tax receipts.3 A large majority of the U.S. public now favors such laws.4
Newer examples of actions that prevent harm by others are the elimination of artificial trans fats from the food supply, which protects people against a contributor to cardiovascular disease, and ignition interlock devices in vehicles, which can protect the public from convicted drunk drivers.
A third key role of government is to protect and promote health through population-wide action. Governmental action is often a more effective and efficient means of protecting public health than the actions of individuals. Immunization mandates, fluoridation of water, iodization of salt, and micronutrient fortification of flour are all classic examples of this type of action; many were controversial initially but are widely accepted today because they save money and reduce illness, disability, and death.
More recent and controversial examples of societal action include zoning laws that require or provide incentives to create bicycling and walking paths or that reduce the neighborhood density of liquor stores. These actions serve entire communities, and individuals cannot feasibly implement them on their own — characteristics that also apply to efforts to reduce sodium in processed and restaurant foods. Objections to such actions usually focus on their costs, effectiveness, or importance, but the appropriate role of government and the relative costs and benefits are also debated. Controversy can be reduced by providing data documenting the health burden and building consensus about the problem and the action’s efficacy. Government action need not consist solely of mandates: micronutrient fortification of food has often been accomplished through voluntary industry actions coordinated through public–private partnerships.
The most controversial public health actions seek to regulate the behavior of adults in such a way as to improve their own health. Public health agencies operate on the belief that government has a valid interest in a healthier populace, but many argue that people have the right to knowingly make decisions that may result in harm to their health. Taxing, decreasing access to, or limiting portion sizes of sugar-sweetened beverages is one example of recent controversial proposals of this type. Seatbelt and motorcycle-helmet laws exemplify the balancing act between health benefits and individual rights: these laws have financial costs for enforcement and the purchase of helmets and perceived societal costs in loss of personal freedom, but they prevent traffic injuries and deaths and reduce societal costs, including health care costs and lost productivity. Such measures may be best enacted at the local or state level, where government’s proper role can be debated; deliberations will be fairest if there are no major vested financial interests, as is generally the case with helmet laws.
Beyond the societal costs in health care and lost productivity, actions to protect health are supported by the recognition that although many people express remorse over past behavior, we tend to assign limited weight to future events or conditions — a pattern behavioral economists call “hyperbolic discounting.” Action by democratically elected leaders may therefore be needed to protect public health over the long term.
Opponents of specific public health actions may believe that the health burden is low, the intervention is too costly or is likely to be ineffective, and that therefore the expected benefits don’t warrant the costs. The costs cited may include financial costs to government, industry, and the economy and to individuals who might not benefit personally. There may also be philosophical objections, such as perceived loss of personal autonomy or the belief that these actions will undermine self-reliance or individual choice. Some opponents fear a slippery slope toward “sabotaging our rights on all fronts.”5
The potential benefits of public health action include economic, health care, and productivity gains, as well as the intrinsic benefit of longer, healthier lives. The dissemination of accurate information on costs and benefits may be the best way to reduce opposition and implement effective public health actions. When government fails to protect and improve people’s health, society suffers. Opponents of public health action often fail to acknowledge the degree to which individual actions are influenced by marketing, promotion, and other external factors. They also may underestimate the health costs of inaction and overestimate the financial or other costs of action. For-profit corporations have a fiduciary responsibility to increase return on investment; some (e.g., tobacco companies) have incentives to oppose actions that may harm their business, even if these actions would promote overall economic development and benefit other businesses. And in some cases, current judicial philosophies may limit possibilities for public health action in the United States.
Government has a responsibility to implement effective public health measures that increase the information available to the public and decision makers, protect people from harm, promote health, and create environments that support healthy behaviors. The health, financial, and productivity gains from public health actions benefit individuals and society as a whole.
This article was published on April 17, 2013, at NEJM.org.
Dr. Frieden is the director of the Centers for Disease Control and Prevention, Atlanta.