Tuesday, October 31, 2006

Our Health Is Public

So, I was listening to the news last evening on my drive home, and I heard this story from NPR. The story is about a hearing before the New York City Health Board about eliminating trans-fats in commercial food. In the midst of this, I was struck by the following quotation. The speaker was Audrey Silk, a retired NYC police officer, Libertarian candidate for mayor, and founder of NYC Citizens Lobbying Against Smoker Harassment. (N.Y.C.CL.A.S.H.)

“You invent for public health a role and a power that it’s never historically had and never ought to have. That’s social engineering. Eliminating choice and coercing behavior is not the American way.”

Now, we could discuss long and hard the just how un-American it is to eliminate choice or coerce behavior. However, I was most struck by her suggestion that this is “a role and a power that [public health] has never historically had.”

First and foremost, how food is cooked in restaurants has long been a public health issue. Inspecting restaurants and overseeing the safe handling of ingredients is nothing new to public health. Neither is deciding that some ingredients simply aren’t safe. That’s why classic absinthe, made with wormwood, is illegal. It’s why cattle “found down,” collapsed alone in the pasture, no longer make it into butcher counters in the United States.

Secondly, there’s hardly any question that trans-fats are as harmful for us as are saturated fats. Adding hydrogen (“hydrogenating”) oils to make them solid and stable at room temperature makes for great ease of use. It also makes for great biscuits and pie crusts (there is no substitute in the Southern kitchen for Crisco!) It just happens to make for blocked arteries for young and old alike.

So, we have a known disease (coronary artery disease) and a significant contributor (trans-fatty acids). How is this not a public health issue? How is this significantly different that cleaning up standing water to reduce mosquitoes?

I have a more basic disagreement with Ms. Silk. She speaks as if these were necessarily matters of private choice, and not of public health. However, private choice or no, all our health is “public.” That’s true because very few of us pay the full cost of our own health care. Most of us have our health care supported by one third party payer or another, whether insurance from government (Medicare, Medicaid, TriCare) or from a private commercial insurer. Yes, we make contributions toward that in the form of co-pays and premiums and salary deductions; but put one of us in the hospital and all of that is covered and exceeded in a matter of hours. We participate in risk pools of various sizes, and so may be able somewhat to adjust our contributions; but few of us pay all of the expenses ourselves.

Indeed, even those who try that, who choose not to participate in insurance plans, end up dragging us into participation. Cost-shifting by providers and insurance requirements by government bodies (for example, to drive a car) are different ways of including the rest of us in the risk pool, and in paying the costs. And that doesn’t even get into support for public educational institutions for physicians, nurses, and other health care professionals – all supported by tax dollars.

That, you know, is the most ironic thing about opposing a single-payer national health plan. We’re already sharing those costs, whether through higher premiums or higher bills due to cost shifting or higher taxes to cover the gaps for a few. A national health insurance plan would spread the risk over the greatest possible number of people, and so offer each of us the lowest relative risk; and at the same time would offer the possibility of efficiencies of scale and of uniformity of forms and charges (check it out: Medicare actually has some of the lowest administrative expenses out there, far lower than most commercial insurers).

In any case, we’re all participating already in health care that is publicly supported, whether we’re honest about it or not. If reducing your trans-fats in restaurants reduces your risk of heart disease, and so your medical expenses, it also reduces my expenses (much less my risk of heart disease). Is that coercive? Perhaps a little. On the other hand, we have an alternative: expect those who choose not to make these decisions and not to carry insurance to actually pay the expenses of their actions. I live in a state that requires motorcyclists to wear helmets, but work in a state that does not. I’ve heard the suggestion that we allow motorcyclists to ride without; and if they crack their heads open, to let them do without – without, that is, expecting the public or an insurer to pick up their Emergency Room bills.

All our health is “public:” publicly supported and publicly funded. So, maybe restricting trans-fats in restaurants isn’t coercive behavior after all. Perhaps it’s as American as a barn-raising or a neighborhood watch. Perhaps it’s just a decision based on a realization of common interest.


Anonymous said...

First, you took Ms Silk's comment out of context. What she said was--or ought to be--safely beyond the realm of the public health bureaucrats was their boast that they were "charged with preventing chronic disease through approaches that address individual behavior." That attempt to engineer--and coerce--people's behavior was what she said was not a legitimate role for Public Health. Had nothing to do with food, it had to do with people.

And note: their claim was about chronic as opposed to communicable disease. When, in fact, chronic diseases have hundreds of possible "causes" (more accurately known as "risk factors"-- since no one can know for sure the true "cause" of a chronic disease--and the answer may be "genetics" or even "God's will.") But should we then ban a couple of hundred things and acts on the premise of "playing safe"?

Just as some people can eat ice cream and stay thin-- and have low cholesterol too--others may get fat, so should we then ban ice cream, eternally and for all? Should we propagandize against it, so that people begin to associate "ice cream" with "death" and coerce them into shunning it? Oh brave new world.

Finally, your argument that personal health is a public duty is an argument shared --and an experiment tried--by the range of totalitarians. Both Hitler and Mao proclaimed the same bad idea. And what a steep slippery slope. Breathes there a soul who doesn't--by dint of personality or taste, or definition of earthly pleasure-- commit some kind of sin against the concept of perfect health? Stay an hour too long at the beach? Love roast beef or good wine--occasionally to excess? Prefer sedentary reading to jogging around the park? Or even cost the general public a lot of money by having too many children?

Where will it all stop if each of us is made to owe an utterly rigid life to the rest of the community and the bureaucrats thereof.

Marshall Scott said...

Walt, thanks for your comment.

It may be that Ms. Silk's comment was taken out of context. I transcribed to the best of my ability her recorded voice in the NPR report. I did try several on line news reports of the meeting, and the NPR statment offered the longest and most complete record from her appearance. I'm sorry if it was out of context. That said, I don't think I misunderstood that she was speaking to a specific issue from a broader position in her political philosophy.

I would still maintain my greatest difference with her. Within our economic system, all of these things already affect us, whether we're aware of it or not. None of us can act with nearly the independence of consequences for others as we may pretend. One person's high health care expenses, however appropriate, will affect the insurance costs and/or the tax rates and/or the available health resources of another person. Since your decisions about your health care will affect my options for my health care, I think I do have some stake in how that happens. We can either make that public and therefore transparent, or we can let it remain undiscussed and undisclosed, delegating control to at best an entirely mechanical market, and at worst to entirely self-interested power-brokers.

Does that require state control? I don't think so. Does it require state involvement? Absolutely; but since we are the state we have the opportunity to participate and shape that participation (unless we distrust our fellow citizens, and so, again, leave it to those self-interested power-brokers). These issues do already affect us all. The institution - the only institution - that is designed to consider all and to be responsive to all is government. Am I always happy with how officials act? Hardly; but when I am unhappy I have access to information (it is, after all, the public business) and I have access to recourse, from the ballot to the right to associate with others who agree; and I have the power of accountability.

My point? It's already happening; and if I don't always like what an official may do, I have more authority with that official than with limited and unnamed shareholders. It's already happening, so let's do it out and above board, and in a way that allow us all a say.