By Scott Burris
We may be living in a golden age of group-think. A weekly reminder is poor Paul Krugman railing against the apparently universal belief in America and Europe that we’ve got to cut budgets right now or disaster will strike. He calls this a Zombie idea, a false claim that has been falsified with plenty of stakes in the heart, silver bullets and blows to the head, but will not stay in the grave.
Closer to home for us in public health is the claim that Americans don’t like government rules regulating their behavior and meddling with their preferences. Cass Sunstein and Richard Thaler have delivered some solid blows to the idea that paternalism typically messes with solid preferences. As we celebrate Public Health Week, I want to highlight two recent papers that show that Americans, like the children in Mary Poppins, actually like their nannies, who do some pretty great things.
Public Health Law Research has recently posted the manuscript of a paper that Evan Anderson and I have prepared for the Annual Review of Law and Social Science. The paper describes the dramatic rise of law as a tool of public health since the 1960s in five major domains: traffic safety, gun violence, tobacco use, reproductive health and obesity. These topical stories illustrate both law’s effectiveness and limitations as a public health tool. They also establish its popularity by the most apt of metrics – the willingness of legislators to enact it. The one picture worth a thousand words, below, depicts the rapid adoption of a variety of interventions by state legislatures. (By the way, the five examples also show that public health law research can and does influence the development and refinement of legal interventions over time.)
The second paper, in the March issue of Health Affairs, comes from Stephanie Morain and Michelle Mello. Their national survey, which gets special marks for using sophisticated measures of legitimacy, finds high levels of public support for a wide range of contemporary health policy interventions.
In previous posts, I have talked about the urgent need for a public health values re-think, in which we who support collective action for well-being look critically at whether we are doing as well as we could in reaching moral concerns beyond the prevention of harm. The M&M study supports this. Health officials get positive marks for substantive performance, marks that seem to track how well they are doing their jobs in various domains. As M&M write, the scores “may reflect a view that the government has done too little, rather than too much,” in areas like smoking, obesity and HIV. But the legitimacy scores are low. I interpret this as reflecting the problem I have written about before – the narrow, harm prevention character of public health values. Reducing health risk is not the sole end of human existence, let alone a sure path to happiness. M&M’s study should make us ask whether we are talking with or talking at a public that is sympathetic with risk reduction but cares about other values too. There is very little support for pursuing smokers into their own homes with bans on private smoking, or making “possession of a controlled soda” or “potato chip trafficking” new disciplinary offenses in school. Do we give too short shrift to the benefits of sweet foods and enjoyable drugs? Are we prepared to accept that some people may prefer a feeling of freedom on a Harley to the sense of safety in a helmet?
The M&M study also supports my view that “new public health” measures raise problems that seat belt and public smoking bans did not. I would bet that the day we can prove to most Americans that Mountain Dew is as dangerous in its own way as cigarettes, we will get majority support for more intrusive regulations, but until that time, we have to give more respect to the public’s skepticism of our expertise – and the legitimacy of our imposing our judgments upon them.
This is not just a matter of messaging about particular interventions. It is also a matter of winning back the public support for collective action for health. Right now, our biggest threat comes not from resistance to a particular intervention – we can actually win most of those fights, at least in the court of public opinion – but in the attempt to undermine the legitimacy of collective action to address the risks arising in daily life. M&M found that the strongest attitudinal predictor of support for a range of measures was the belief that “public health officials understand the public’s values.”
So next time some Zombie gets up and starts to complain about the nanny state, just repeat Stuart Smalley’s public health mantra: “We’re Good Enough, We’re Smart Enough, and Doggone It, People Like Us.”
