Running scared

The newly published alcohol harm reduction strategy sets out
measures to protect citizens from some of the worst effects of
drinking. It begs the question: how far should government intervene
to protect us from risks to our health?

Like “political correctness”, the phrase “nanny state” seems to be
a strong deterrent to some government action. The Blair
administration is probably more prone to control freakery than any
government since the second world war, but is highly averse to
being accused of “nanny statism”. To protect itself from the
charge, it has taken to evangelising about the need to promote
individual choice. Meanwhile the public has signalled that it
doesn’t really want choice in public services, it just wants good
services.

A recent BBC opinion poll shows heavy support for government
intervention in what many would see as matters of personal choice.
Seventy-three per cent say they want a ban on smoking in public
places; 72 per cent want junk food and fizzy drinks banned from
school premises and 65 per cent want government health warnings on
bottles of alcohol. The government is lagging behind the public on
these issues – not least because it fears attracting the nanny
tag.

It is time to think carefully about the boundaries and overlaps
between the responsibilities of the individual and the state.

Individuals are not just passive consumers of health services but
active producers of their own health and well being. What we know,
how we use our knowledge and how we behave and make decisions all
profoundly influence our health. In addition, our sense of autonomy
and control over our lives are factors that make a significant
contribution to our mental and physical well being. So freedom is
to be cherished not just as a political value, but as an important
determinant of health.

Yet our choices are thoroughly constrained – by how much we earn,
where we live, how well educated we are and much else. You can’t
choose to eat healthy food, for instance, unless you know what is
healthy, can find where to buy it and can afford to pay. You can’t
choose to take exercise if your work and family responsibilities
leave you no extra time, if you can’t afford to buy a bicycle or
join a gym, or if your local streets are unsafe for
pedestrians.

And sometimes the choices of one individual can put their health at
risk, for example, by driving dangerously or smoking indoors near
children, or having unprotected sex. If I drink heavily, eat fatty
foods and fail to take exercise, I am more likely to get ill and
need your taxes to pay for my health care. If I fail to save for a
decent pension, I am more likely to be poor in retirement and more
vulnerable to illness and dependency, needing a range of publicly
funded services.

So individual choice only works positively for health in the
context of a close relationship with responsible government acting
on behalf of the whole population.

This involves at least five functions. The first is to facilitate
the gathering, analysing and dissemination of information about the
causes of health and illness. The second is to set a good example
through its own behaviour. The third is to create the conditions
for equal choice, though education, employment, housing and
neighbourhood policies, so that everyone can choose healthy
lifestyles, regardless of their background. The fourth is to try
and make sure that, in the interests of society as a whole, every
individual takes reasonable steps to safeguard their health and
well being in the long term. The fifth is to discourage or prohibit
individual or corporate behaviour that endangers the health of
other people.

Whether any of this is achieved through information, education,
exhortation or legislation should depend on the severity of the
risk and on evidence – if it exists – of the willingness or
otherwise of the parties involved to act voluntarily. Jumping
straight in with a legal ban may not be the best way to encourage
responsible behaviour by citizens or corporations. But if all else
fails, then compulsion may be necessary.

According to the BBC poll, people are quite grown-up enough to
understand that some freedoms must be curtailed for the sake of
more precious ones.

Anna Coote is director of public health at The King’s
Fund.