Mini-SymposiumNanny or steward? The role of government in public health
Introduction
The past year has seen contentious debates about public health in England around smoking bans, 24 hour licencing for alcohol, and junk food advertising. Critics of government policy have been quick to label proposed measures ‘nanny statist’ and an unnecessary intrusion into people's personal lives. Government has been equally quick to distance itself from an old-style interventionist state.
Dismissing government interventions as nanny statist precludes debate about options open to government and their likely impact on population health. This paper suggests that there is a strong argument to be made for government intervention to safeguard public health. Legislation brings about changes that individuals on their own cannot, and sets new standards for the public good. Rather than condemning such activity as ‘nanny statist’, it might be more appropriate to view it as a form of ‘stewardship’.
This paper begins by examining the ‘nanny state’ debate in England, looking at examples from the past and today. It then looks at international evidence about alcohol use, smoking and road safety, to show how taxation, regulation and education create a public health framework and shapes individual choices towards healthier and safer behaviour. It concludes with reflections on the impact of government intervention, and suggests that stewardship might be a more appropriate concept than ‘nanny’ as a way to envision a government's role around protecting and promoting health.
Section snippets
Intervention or freedom: the nanny state debate
The debate over the limits to state intervention and extent of individual freedom weaves through the history of public health. In the simplest terms, it divides between interventionists and libertarians. For interventionists, governments promote freedom for individuals by creating opportunities and levelling out inequities in society. For libertarians, minimal government is the best way to protect individual freedom, which is about not being interfered with by others.
Regulations we now take
Taxation
International studies show that increasing the price of alcohol generally leads to a decrease in consumption, with a positive follow-on effect for public health. In the UK alcohol consumption has increased as the price of alcohol relative to income has fallen and tax has fallen in real terms.15, 16 Countries that increase the price of alcohol through tax find that consumption decreases. In 1992, the Northern Territory in Australia introduced a harm reduction levy on all drinks with over 3%
Regulation to restrict access
Completely banning access to alcohol or tobacco would be politically unacceptable, and most likely encourage illegal use. However, restricting access to alcohol and tobacco seems to reduce consumption rates, and brings wider social and health benefits.
Certainly liberalizing licencing laws encourages increased consumption of alcohol. When Sweden allowed its liquor stores to open on Saturday, sales of alcohol increased, and so did rates of domestic violence and public drunkeness. As a result, the
Advertising bans
Total advertising bans are associated with declining consumption of alcohol and tobacco which leads to declining morbidity and mortality from related illnesses. Reducing exposure to positive images of smoking and drinking changes attitudes to these behaviours.
Research suggests that advertising shapes positive attitudes to drinking.29, 30, 31 A study that compared 17 countries over a 13-year period found that those with total bans on beer, wine and spirits advertising had lower alcohol
Proscribing behaviour
Smoking bans work through peer pressure, but wearing seatbelts and not driving when drunk depend on the state proscribing permitted behaviour and using surveillance and penalties to ensure compliance.
For example, Britain was one of the first countries to require front seat belts to be fitted to cars in 1965. Adoption rates were low until it made front seatbelt use compulsory for drivers and front-seat passengers in 1983, rear seatbelt use mandatory for children in 1989, and rear seatbelt use
Education
Health awareness programmes aim to change individuals’ knowledge and attitudes about risks related to health, in the hope this will affect behaviour. The evidence is equivocal about their effect.
Studies of mass media alcohol campaigns show that they are cost effective, because they reach a high percentage of their target audience, but they have only some impact on knowledge and attitudes and little impact on behaviour.16 Evaluations of school-based information and normative programmes show they
Conclusions
Almost every government intervention in the public health arena has been criticized by commentators of the time as a sign of tyranny, nanny statism, or the end of individual freedom. Yet the evidence discussed above illustrates the considerable individual and public health benefits of once-contested interventions—results, which arguably mitigate the small limitations on individual freedom and choice. The findings show the positive impact of education, taxation, and restrictive legislation on
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