Watching the news about the Royal Wedding from the other side of the Atlantic when I could for the first year consider London my “homeplace” feels a little bit strange, but actually nice, as it is nice to be able to discuss Kate’s dress or William’s uniform with the other Londoners participants at the 6th Annual International Bioethics conference, pretending to be sad to be missing it, but actually being happy to be out of the chaos. Dan Wikler (Professor of Ethics, Harvard School of Public Health) was in charge of the opening remarks of the conference, organized by the Harvard University Program in Ethics & Health and sponsored by the World Bank, the Edmond J. Safra Center for Ethics and the Harvard Kennedy School of Law.
The focus this year was on new strategies for health promotion: carrots or sticks? As put by Nir Eyal (Assistant Professor of Global Health & Social Medicine at the Harvard Medical School) and one of the organizers of the event (together with Dan Wikler and Maureen Lewis of the World Bank), the very dense 2-day program -which put together around 40 speakers among ethicists, economists, policy makers, lawyers and regulators – aimed at raising ethical questions deriving from strategies aimed at implementing health, as such: when does an intervention count as too intrusive, or trumping individual’s autonomy? Which strategies are legitimate, and on which basis? What are the goals and principles of public health ethics, versus clinical ethics? And, how to resolve potential conflicts between the two?
Andrew Goodman, Deputy Commission, Health Promotion and Disease Prevention (NYC Department of Health & Mental Hygiene) opened the morning session, presenting examples of strategies aimed at “making newyorkers healthier”, and implemented under the Bloomberg administration. Most of those policies are tackling the tobacco and obesity epidemic. As to the former, the Smoke Free Air Act (SFAA), being a complete ban, ensures that smoking is prohibited even in public open spaces, such as gardens and parks. The rationales for the ban are based not only on the harms derived from passive smoking (an argument that becomes weaker in a public and open space), but also on the ‘repulsive garbage’ argument (i.e. too many butts on the streets), and on the supposed right of parents (or children, it is not clear whose right it is) of not having their children see the bad model purported by people smoking.
As to the latter, policies aimed at tackling the obesity epidemic with the associated increased heart risks, such as the augmented risk of coronary heart disease (CHR), the TransFat Regulation which was passed in December 2006 superseded a previously ineffective campaign aimed at educating people about the risks derived from food containing transfats. The current regulation prohibits the selling of transfat containing food (for a complete list click here) and has jurisdiction over restaurants and vending machines. Another campaign called NSRI (National Salt Reduction Initiative) aims at the gradual reduction in the food salt content, and at reducing risks derived from an excessively high arterial pressure. Around thirty companies are collaborating, and the number is increasing. But the most provocative policy presented by Goodman revolves around banning sugary drinks (basically all pop, soda, fizzy drink, or carbonated beverages). The NYC Department of Health & Mental Hygiene submitted last fall an application to the US Department of Agriculture (USDA) to allow a 2-year demonstration to cut soda & pop drinks, and a 360 degrees campaign on tv and other media has been implemented. Click here to watch one of the video of the “Pouring on the pounds” campaign to cut soda drinks, showing a man drinking fat. Quite effective in eliciting disgust, ain’t it?
Some have criticized NYC health promotion strategies implemented under the Bloomberg administration, as being way too direct, and intrusive of the private sphere. I will leave this issue aside for the moment, and note instead that all the policies described above are not directed at steering the individuals’ beahavior (at least not so directly), but are directed at regulating the food industry, the rationale being that in order to be effective such policies must act at the level of the social context in which the individuals are embedded. Plenty of data demonstrate indeed the ineffectiveness of policies aimed at educating the individual, of which the first campaign to cut transfat containing food is only an example. This line of reasoning is in agreement with the recent April 2011 editorial by the Journal of Public Health Policy . In here the editors Anthony Robbins (Tufts) and Marion Nestle (NYU)
encourage authors to come up with new strategies aimed at tackling the obesity epidemic, but focused on considering how to change the behavior of the food industry, not of the individuals.
As put by Robbins and Nestle, “We have come to believe that research studies concentrating on personal behavior and responsibility as causes of the obesity epidemic do little but offer cover to an industry seeking to downplay its own responsibility”. In other words, paraphrasing emeritus epidemiologist Geoffrey Rose, “Mass diseases and mass exposures require mass remedies”. Policies aimed at influencing only individual behaviors will not make the trick. NYC Bloomberg’s policies may do so. Even if they may be ‘too much in your face’. Yuck!
Chan, Sewell New Targets in the Fat Fight: Soda and Juice, New York Times, August 31, 2009.
Goodman, Andrew President Obama’s health plan and community-based prevention. Am J Public Health. 2009 Oct
Rose, Geoffrey. The Strategy of Preventive Medicine Oxford University Press, 1993.