Is it our job alone to look after our health? Or do employers, insurers, for-profit companies and the government also share some responsibility to keep us healthy? One person's nanny state is another's public health salvation. There is no shortage of examples of opposing perspectives:
The World Health Organization (WHO), in a study published earlier this month, found that if governments regulated fast foods more heavily, they could slow or even reverse the growing obesity epidemic. This recommendation garners praise or criticism depending on whom you ask.
Writing about reforms like these, Dr. David Katz, a preventive medicine specialist, observes, "In one corner is the group that invokes personal responsibility as the answer to all ills. We need no regulation, we need no environmental reforms, we need no food control, or gun control... We just need to make good choices. In the other corner are environmental determinists who, at the extreme, might wait around for someone to spoonfeed the quinoa and escort them to the gym." The answer lies somewhere in the middle, he says, "The choices any of us makes are subordinate to the choices we have."
Mark Bittman echoed Katz's observations in The New York Times in Rethinking Our 'Rights' to Dangerous Behaviors: "All of these industries work hard to defend our 'right' – to smoke, feed our children junk, carry handguns and so on – as matters of choice, freedom and responsibility. Their unified line is that anything that restricts those 'rights' is un-American. Yet each industry, as it (mostly) legally can, designs products that are difficult to resist and sometimes addictive."
Restrictions on smoking, while they vary around the U.S., have generally expanded over the years, and such legislation is often credited with declining rates. New York City is set to become one of the only U.S. cities to raise the legal smoking age to 21. "This is literally legislation that will save lives," said New York City Council speaker Christine Quinn. Also, the mega-chain pharmacy CVS announced this month that it will no longer sell tobacco products as of October 1 of this year. "[This] is the right thing for us to do for our customers and our company to help people on their path to better health," said president and CEO Larry Merlo.
What about alcohol consumption? According to a study published online February 10 in The Lancet, raising the minimum price for alcohol would benefit the health of high-risk drinkers with low incomes by discouraging their alcohol purchases. Some argue that policies that focus on increasing the cost of "risky" choices are unfair – that they don't impact all consumers equally.
It seems obvious that the job of clinicians and the health care system is to take care of people when they're sick, but the impact of those thousands of individual health behaviors plays out on a larger scale. In the closing of a recent Journal of the American Medical Association article, Finding the Role of Health Care in Population Health, the authors write: "The increasing inclusion of a population perspective is not a natural evolution for the U.S. health care system. In fact, it is counter-cultural in a society that values personal independence and is often mistrustful of the centralized efforts of large organizations, public or private. However, the pressure to change is evident in the form of poor population-level outcomes, unsustainable costs, and persistent disparities. Clarifying both the potential actions and the challenges for health care systems in promoting population health may allow the setting of new, if ambitious, expectations for what can be achieved."
Regardless of rules or regulations, managing our health and health care is mostly up to us. As CFAH president Jessie Gruman notes, "We will not always be able to keep our eyes on the prize as defined by our clinicians. But we can be greatly helped by knowing what options we have, what they cost in terms of time and money, and how they may affect our ability to work and play... Without my efforts, all that beautiful science, all those marvelous innovations – the surgeries, the drugs, the devices – all my clinicians' experience and advice would have no effect. I have to do the best I can to show up, get the tests, eat as directed, take the pills, follow the advice and coordinate my care or I will not realize the benefit."