View Article PDF

Our health and wellbeing are largely determined by underlying social, economic, cultural and environmental factors, and the effectiveness of health services.1 Improving health equitably requires strong leadership from all relevant sectors to encourage (nudge) individuals and groups to make healthy choices. Although this leadership comes primarily from government, with much of it expressed through the Ministry of Health, it also comes from other stakeholders such as the education, finance and transport ministries, non-governmental organisations (NGOs), commercial organisations, and the community as a whole.The perception that health is predominantly a matter of individual choice or personal responsibility presents a barrier to government leadership. Governments may be accused of interfering in individuals' freedom to choose their own behaviours, irrespective of their health impacts. No one likes authoritarian restriction of their choices, especially when the rationale for restrictions is not adequately explained. Criticism of so called ‘nanny state' intervention can resonate with governments and reduce their resolve to act in the best interests of the population, especially the most vulnerable members—children, marginalised ethnic groups, and socioeconomically deprived groups. The ‘nanny state' label inhibits the constructive debate required to reach agreement on the best way of promoting the health of all New Zealanders.The public health community must promote discussion of the balance between protecting public liberties and improving the health of the population. This debate has much in common with discussions over the desirability of free markets and government intervention in the economy; a balance of roles is usually indicated.2 In promoting debate the public health community must build strong community links so that public health interventions are perceived as being warranted.This paper analyses the role of the state and other key sectors in providing strong and balanced health leadership. It also explores how language is used to frame debates about competing models of health leadership, and makes recommendations about the leadership required to address the major health challenges facing New Zealand.The roles of the state, non-government organisations and the commercial sectorRole of the state—Most New Zealanders would agree with Nobel laureate Amartya Sen that the state has fundamental responsibilities to protect the political rights and liberties of its citizens, as well as their health and wellbeing.3 In the exercise of health leadership, these two duties may come into conflict. This issue is at the heart of public and political debates. In a vibrant democracy the boundaries of legitimate state action should be under constant scrutiny and negotiation.For example, unhealthy diets increase the risk of heart disease, stroke, cancer and diabetes, all of which are key causes of premature death in New Zealand.4 Although the role of government in promoting healthier dietary choices is debated, arguments that individuals exercise complete personal autonomy in their eating choices are flawed.Food production, marketing, and promotion exert powerful influences on individuals' choice and consumption patterns. The eating environment shapes and constrains behaviour, particularly among young people, who are more vulnerable to marketing promotions.5,6 To balance these influences, the state has an essential role in creating a context that simplifies and facilitates healthy choices.The state also has an essential role in ensuring equitable health outcomes and addressing inequities. In New Zealand this duty applies, for example, to Māori and Pacific populations, and low-income groups.Role of NGOs—In New Zealand's pluralistic democracy, the government sometimes struggles to respond fully to minority and local needs because of the political constraints imposed by the ‘median voter' (the pressure for government to respond to the apparent wishes of the majority).7(p111),8(p5) Furthermore, government policy is vulnerable to capture by powerful industry interest groups, such as the food, tobacco and alcohol industries.9,10NGOs have a special role in identifying and resisting the capture by vested interests of regulatory bodies charged with protecting the public interest. By contracting with the voluntary sector, government may achieve health gains which may not be possible through direct state intervention. New Zealand's experience with HIV/AIDS illustrates the mutual dependence and co-operation of the state and the NGO sector through the Ministry of Health, the dominant funder of the AIDS Foundation. Gay men and women initiated a community-based response to the epidemic to conduct effective education and health promotion and political lobbying of the government for funds to support the AIDS Foundation.11(p221-227)The NGO sector has a complementary role to government—it represents a vehicle for indigenous self-determination, caters for minority populations, and can experiment with policy options. Nevertheless, there are potential weaknesses of the NGO sector: it may serve as an ineffective ‘convenient solution' for government; its activities may loosen democratic accountability, and it may serve as a vehicle for disguised profit making.7(p11) A fuller account of the respective roles of government, the private for-profit sector and the private non-profit sector can be found elsewhere.12,13Role of the commercial sectorWhat role does the commercial sector have in providing public health leadership? While the ‘median voter' may constrain government's pursuit of equity, shareholders' interests and the drive to maximise profit constrain for-profit organisations. In particular, major commercial interests are generally blind to the special needs of minority groups and vulnerable populations. Further, the existence of market failures in health, and the consequent need for government corrective action via regulation, limits the role of the commercial sector in health leadership.13Economic theory argues that perfect markets permit the free exchange of goods and services between consumers and producers. Optimal outcomes depend on certainty (consumers must know what they want, and when and where they can obtain it); no externalities (unintended consequences of people's production or consumption of services); perfect knowledge (patients must know about their diagnoses and the full range of prevention or treatment options); the absence of self-interested advice from health care professionals; and the presence of numerous small producers with no market power.14(p24-28) These conditions are rarely, if ever, met in health care, thereby justifying the comprehensive government intervention that occurs in many countries.14(p24-28),15(p4816,p272)Notwithstanding problems with market failure, in some circumstances it is desirable (as with food safety), for the public health community to work with the commercial sector to promote independently monitored public health goals.When should governments intervene?We support the arguments made by the Nuffield Council on Bioethics, which describe when government intervention is justified.17 The Council's principles suggest an ‘intervention ladder' to inform government actions (Table 1). The Council notes that the higher up the ladder government intervention occurs, the stronger the evidence needs to be. Table 1. Government leadership for health—an ‘intervention ladder' Eliminate choice. Regulate to entirely eliminate choice, for example through compulsory wearing of seatbelts and cycle helmets. Restrict choice. Regulate to protect people by reducing options; for example, restricting the sale of cigarettes and alcohol to protect minors. Guide choice through disincentives. Fiscal and other disincentives can influence people not to pursue certain activities, for example imposing taxes on cigarettes, or limiting parking spaces to discourage the use of cars in inner cities. Guide choices through incentives. Regulations can guide choices by fiscal and other incentives, such as the provision of subsidised public transport and building high quality cycle lanes with cycle and pedestrian-friendly road layout to promote greater use of public and active transport. Guide choices through changing the default policy. For example, through the ABC smoking cessation programme the default interaction of New Zealand health practitioners with people now should involve specific questions about smoking and, if relevant, cessation advice.18 Enable choice. Enable individuals to change their behaviours, for example by offering participation in a ‘stop smoking' programme, building cycle lanes, or providing free fruit in schools. Provide information. Inform and educate the public, for example as part of campaigns to encourage people to walk more or eat five portions of fruit and vegetables per day. Do nothing or simply monitor the situation as was the case for many years with campylobacter infection sourced from chicken.19 Adapted from: Nuffield Council on Bioethics (2007). Public Health: ethical issues. London, Nuffield Council on Bioethics. Deconstructing ‘nanny state' language As Table 1 makes clear, health leadership may take many forms; ranging from observation and monitoring at one end, to restriction and elimination of choices at the other.20 The former options rely on personal responsibility and assume individuals acquire and assess information, apply it to their own circumstances, and make a decision about how they will act. However, this presumes that people have free access to easily understood information, understand the longer-term consequences of competing actions, and are willing to trade short term benefits off against future costs. Furthermore, it assumes information will be sufficiently powerful to outweigh other factors, such as marketing incentives, that discourage healthier behaviours. Lang and Rayner highlight the logical absurdity of extreme ‘individual responsibility' arguments: “circumstances of free information circulation, people ‘choose' to be overweight simply because they eat too much and do too little... In fact, such propositions are deeply flawed... Population weight gain is occurring in conditions of growing ‘health consciousness'”. 21 Because of the difficulties individuals may have in locating relevant and useful information, and the factors that may impede their use of it, the other end of the leadership continuum involves greater action by governments. Here, regulators will intervene to create environments that encourage healthier choices, typically by making these more visible or accessible, or eliminate unhealthy choices, normally by removing their availability.22 Governments have constrained choices and even coerced behaviours in several situations, particularly where these would pose serious risks to others. Thus regulations have modified environments (smokefree laws), imposed limits on behaviour (permissible blood alcohol levels for driving), restricted access to products (cold medications able to be made into pseudoephidrine), and required the adoption of new behaviours (mandatory use of cycle helmets) and the relinquishment of existing behaviours (cellphone use while driving). These examples illustrate changes that reduce third party risk to individuals and, while not all were initially widely accepted, each has achieved high levels of public acceptance and satisfactory compliance. Although the evidence indicates that regulation brings about more rapid behaviour change, critics argue that these measures reduce the role individuals play in charting their own destiny, and make them little more than “just a pawn in a societal game”.23 This may explain why governments have been more reluctant to introduce regulatory initiatives that would reduce risks individuals may pose to themselves.24 25 Framing the debate; the power of language Instead of debating the evidence relating to public health measures, recent discussions have focussed more on framing the debate than they have on analysing its premises or the likely effect of different measures. For example, policies that altered school food supply were described as ‘nanny statist', and therefore undesirable, when introduced to New Zealand schools in 2007. The media carried surprisingly little discussion about the likely benefits these policies could bring. Advertisers and marketers have always known that language exerts a powerful influence.26 It is not surprising that metaphors such as the ‘nanny state' are used to shape consumers' views on government actions, particularly when these could constrain marketers' freedoms.27 The ‘nanny state' metaphor is now widely used in attempts to discredit initiatives that propose intervening in or constraining ‘the market', such as the removal of junk food from schools. A nanny state has been equated to one governed by despots no longer satisfied with issuing regulations, but bent on acquiring autocratic powers that enable them to become ‘the food police'. Jochelson was alert to these problems when she warned of the need to recognise rhetorical strategies, which she claimed were the antithesis of logical debate: “Dismissing government intervention as nanny-statist limits debate about the possible benefits of state intervention”.28, p. 1151 The nanny state metaphor may simplify a complex political debate, but does so by distorting familiar images and impeding a detailed understanding of the claims advanced. Conclusion and recommendations Government has an obligation to act to protect the health of its citizens, both in respect of traditional threats to health, such as infectious diseases, and in response to newer threats, such as diet. We recommend that government uses allsteps on the intervention ladder where these are supported by compelling public health evidence. We recommend that health policy decisions have a clear evidence base and equity rationale, where the proposed interventions have been balanced against the freedom of individuals to act on their own account without undue influence from marketing. In exercising its health leadership for the general population and in addressing the health needs of under-served or marginalised groups, we recommend that government draws on the experience and expertise of the NGO and public health sectors as well as communities, thus ensuring responsiveness to local needs. We recommend that public health practitioners place strong emphasis on communication links with communities thereby building constituencies so that public health decision-making does not occur predominantly in the bureaucratic domain. Government, the public and civil society should actively reject debates where complex issues are over-simplified or reduced to polemical and manipulative sound bites. We recommend that government actively promote wide-ranging debates that draw on and test the available evidence.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Peter Crampton, Pro-Vice-Chancellor, Division of Health Sciences, University of Otago; Janet Hoek, Professor, Department of Marketing, University of Otago, Dunedin; Robert Beaglehole, Emeritus Professor, University of Auckland, Auckland

Acknowledgements

Correspondence

Professor Peter Crampton, Pro-Vice-Chancellor, Division of Health Sciences, University of Otago, PO Box 647, Dunedin, New Zealand. Fax +64 (03) 4795058;

Correspondence Email

Peter.Crampton@otago.ac.nz

Competing Interests

None

- World Health Organization CoSDoH. Closing the Gap in a Generation, Health Equity Through Action on the Social Determinants of Health. Geneva: World Health Organization, 2008.-- Stiglitz JE. Freefall: America, Free Markets, and the Sinking of the World Economy. New York: WW Norton, 2010.-- Sen A. Development As Freedom. New York: Anchor Books, 2000.-- Ministry of Health. Looking Upstream, Causes of death cross-classified by risk and condition New Zealand 1997. Wellington: Ministry of Health, 2004.-- Nestle M. Soft drink cpouring rights:d marketing empty calories. Public Health Reports 2000;115:308-19.-- Nestle M. Food marketing and childhood obesitya matter of policy [Perspective]. New England Journal of Medicine 2006;354:2527-28.-- Salamon L. Partners in public service: the scope and theory of government-nonprofit relations. In: Powell W, editor. The Nonprofit Sector A Research Handbook. New Haven: Yale University Press, 1987.-- Smith S, Lipsky M. Nonprofits for hire, The Welfare State in the Age of Contracting. Cambridge, Massachusetts: Harvard University Press, 1993.-- Brownell K, Warner K. The Perils of Ignoring History: Big Tobacco Played Dirty and Millions Died. How Similar Is Big Food? . Milbank Quarterly 2009;87:259-94.-- Roper B. Business political activity in New Zealand from 1990 to 2005. K 014dtuitui: New Zealand Journal of Social Sciences Online 2006;1:161-83.-- Davis P, Lichtenstein B. A viable partnership? In: Davis P, editor. Intimate Detail & Vital Statistics; Aids, Sexuality and the Social Order in New Zealand. Auckland: Auckland University Press, 1996.-- Crampton P, Dowell A, Woodward A. Third sector primary care for vulnerable populations. Social Science and Medicine 2001;53:1491-502.-- Crampton P, Starfield B. A case for government ownership of primary care services in New Zealand: weighing the arguments. International Journal of Health Services 2004;34:709-29.-- Donaldson C, Gerard K, Jan S, et al. Economics of Health Care Financing, The Visible Hand (Second Edition). Basingstoke: Palgrave Macmillan, 2005.-- McPake B, Normand C. Health Economics, An International Persective (Second Edition). Oxford: Routledge, 2008.-- Rice T. The Economics of Health Reconsidered (Second Edition). Chicago: Health Administration Press, 2002.-- Nuffield Council on Bioethics. Public Health: ethical issues. London: Nuffield Council on Bioethics, 2007.-- McRobbie H, Bullen C, Glover M, et al. New Zealand smoking cessation guidelines. New Zealand Medical Journal 2008;121(1276). http://www.nzmj.com/journal/121-1276/3117/content.pdf-- Baker M, Wilson N, Edwards R. Campylobacter infection and chicken: an update on New Zealand's largest 'common source outbreak' (letter). New Zealand Medical Journal 2007;120(1261). http://www.nzmj.com/journal/120-1261/2717/content.pdf-- Calman K. Beyond the nanny state: Stewardship and public healthBeyond the nanny state: Stewardship and public health. Public Health 2009;123:e6-e10.-- Lang T, Rayner G. Overcoming policy cacophony on obesity: An ecological public health framework for policymakers. Obesity Reviews 2007;8 (suppl 1):165-81.-- Thaler R, Sunstein C. Nudge: Improving Decisions About Health, Wealth, and Happiness. New Haven: Yale University 2008.-- Connelly J. Public health policy: Between victim blaming and the nanny state - will the third way work? Policy Studies 1999;20:51-67.-- Baron J. Medical police and the nanny state: public health versus private autonomy. Mount Sinai Journal of Medicine 2006;73:708-15.-- Kersh R, Morone J. Obesity, Courts, and the New Politics of Public Health. Journal of Health Politics Policy and Law 2005;30:839-68.-- Woodside A, Sood S, al e. When consumers and brands talk: storytelling theory and research in psychology and marketing. Pscyhology & Marketing 2008;25:97-145.-- Daube M, Stafford J, al e. No need for nanny. Tobacco Control 2008;17:426-27.-- Jochelson K. Nanny or steward? The role of government in public health. Public Health 2006;120:1149-55.-

For the PDF of this article,
contact nzmj@nzma.org.nz

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Our health and wellbeing are largely determined by underlying social, economic, cultural and environmental factors, and the effectiveness of health services.1 Improving health equitably requires strong leadership from all relevant sectors to encourage (nudge) individuals and groups to make healthy choices. Although this leadership comes primarily from government, with much of it expressed through the Ministry of Health, it also comes from other stakeholders such as the education, finance and transport ministries, non-governmental organisations (NGOs), commercial organisations, and the community as a whole.The perception that health is predominantly a matter of individual choice or personal responsibility presents a barrier to government leadership. Governments may be accused of interfering in individuals' freedom to choose their own behaviours, irrespective of their health impacts. No one likes authoritarian restriction of their choices, especially when the rationale for restrictions is not adequately explained. Criticism of so called ‘nanny state' intervention can resonate with governments and reduce their resolve to act in the best interests of the population, especially the most vulnerable members—children, marginalised ethnic groups, and socioeconomically deprived groups. The ‘nanny state' label inhibits the constructive debate required to reach agreement on the best way of promoting the health of all New Zealanders.The public health community must promote discussion of the balance between protecting public liberties and improving the health of the population. This debate has much in common with discussions over the desirability of free markets and government intervention in the economy; a balance of roles is usually indicated.2 In promoting debate the public health community must build strong community links so that public health interventions are perceived as being warranted.This paper analyses the role of the state and other key sectors in providing strong and balanced health leadership. It also explores how language is used to frame debates about competing models of health leadership, and makes recommendations about the leadership required to address the major health challenges facing New Zealand.The roles of the state, non-government organisations and the commercial sectorRole of the state—Most New Zealanders would agree with Nobel laureate Amartya Sen that the state has fundamental responsibilities to protect the political rights and liberties of its citizens, as well as their health and wellbeing.3 In the exercise of health leadership, these two duties may come into conflict. This issue is at the heart of public and political debates. In a vibrant democracy the boundaries of legitimate state action should be under constant scrutiny and negotiation.For example, unhealthy diets increase the risk of heart disease, stroke, cancer and diabetes, all of which are key causes of premature death in New Zealand.4 Although the role of government in promoting healthier dietary choices is debated, arguments that individuals exercise complete personal autonomy in their eating choices are flawed.Food production, marketing, and promotion exert powerful influences on individuals' choice and consumption patterns. The eating environment shapes and constrains behaviour, particularly among young people, who are more vulnerable to marketing promotions.5,6 To balance these influences, the state has an essential role in creating a context that simplifies and facilitates healthy choices.The state also has an essential role in ensuring equitable health outcomes and addressing inequities. In New Zealand this duty applies, for example, to Māori and Pacific populations, and low-income groups.Role of NGOs—In New Zealand's pluralistic democracy, the government sometimes struggles to respond fully to minority and local needs because of the political constraints imposed by the ‘median voter' (the pressure for government to respond to the apparent wishes of the majority).7(p111),8(p5) Furthermore, government policy is vulnerable to capture by powerful industry interest groups, such as the food, tobacco and alcohol industries.9,10NGOs have a special role in identifying and resisting the capture by vested interests of regulatory bodies charged with protecting the public interest. By contracting with the voluntary sector, government may achieve health gains which may not be possible through direct state intervention. New Zealand's experience with HIV/AIDS illustrates the mutual dependence and co-operation of the state and the NGO sector through the Ministry of Health, the dominant funder of the AIDS Foundation. Gay men and women initiated a community-based response to the epidemic to conduct effective education and health promotion and political lobbying of the government for funds to support the AIDS Foundation.11(p221-227)The NGO sector has a complementary role to government—it represents a vehicle for indigenous self-determination, caters for minority populations, and can experiment with policy options. Nevertheless, there are potential weaknesses of the NGO sector: it may serve as an ineffective ‘convenient solution' for government; its activities may loosen democratic accountability, and it may serve as a vehicle for disguised profit making.7(p11) A fuller account of the respective roles of government, the private for-profit sector and the private non-profit sector can be found elsewhere.12,13Role of the commercial sectorWhat role does the commercial sector have in providing public health leadership? While the ‘median voter' may constrain government's pursuit of equity, shareholders' interests and the drive to maximise profit constrain for-profit organisations. In particular, major commercial interests are generally blind to the special needs of minority groups and vulnerable populations. Further, the existence of market failures in health, and the consequent need for government corrective action via regulation, limits the role of the commercial sector in health leadership.13Economic theory argues that perfect markets permit the free exchange of goods and services between consumers and producers. Optimal outcomes depend on certainty (consumers must know what they want, and when and where they can obtain it); no externalities (unintended consequences of people's production or consumption of services); perfect knowledge (patients must know about their diagnoses and the full range of prevention or treatment options); the absence of self-interested advice from health care professionals; and the presence of numerous small producers with no market power.14(p24-28) These conditions are rarely, if ever, met in health care, thereby justifying the comprehensive government intervention that occurs in many countries.14(p24-28),15(p4816,p272)Notwithstanding problems with market failure, in some circumstances it is desirable (as with food safety), for the public health community to work with the commercial sector to promote independently monitored public health goals.When should governments intervene?We support the arguments made by the Nuffield Council on Bioethics, which describe when government intervention is justified.17 The Council's principles suggest an ‘intervention ladder' to inform government actions (Table 1). The Council notes that the higher up the ladder government intervention occurs, the stronger the evidence needs to be. Table 1. Government leadership for health—an ‘intervention ladder' Eliminate choice. Regulate to entirely eliminate choice, for example through compulsory wearing of seatbelts and cycle helmets. Restrict choice. Regulate to protect people by reducing options; for example, restricting the sale of cigarettes and alcohol to protect minors. Guide choice through disincentives. Fiscal and other disincentives can influence people not to pursue certain activities, for example imposing taxes on cigarettes, or limiting parking spaces to discourage the use of cars in inner cities. Guide choices through incentives. Regulations can guide choices by fiscal and other incentives, such as the provision of subsidised public transport and building high quality cycle lanes with cycle and pedestrian-friendly road layout to promote greater use of public and active transport. Guide choices through changing the default policy. For example, through the ABC smoking cessation programme the default interaction of New Zealand health practitioners with people now should involve specific questions about smoking and, if relevant, cessation advice.18 Enable choice. Enable individuals to change their behaviours, for example by offering participation in a ‘stop smoking' programme, building cycle lanes, or providing free fruit in schools. Provide information. Inform and educate the public, for example as part of campaigns to encourage people to walk more or eat five portions of fruit and vegetables per day. Do nothing or simply monitor the situation as was the case for many years with campylobacter infection sourced from chicken.19 Adapted from: Nuffield Council on Bioethics (2007). Public Health: ethical issues. London, Nuffield Council on Bioethics. Deconstructing ‘nanny state' language As Table 1 makes clear, health leadership may take many forms; ranging from observation and monitoring at one end, to restriction and elimination of choices at the other.20 The former options rely on personal responsibility and assume individuals acquire and assess information, apply it to their own circumstances, and make a decision about how they will act. However, this presumes that people have free access to easily understood information, understand the longer-term consequences of competing actions, and are willing to trade short term benefits off against future costs. Furthermore, it assumes information will be sufficiently powerful to outweigh other factors, such as marketing incentives, that discourage healthier behaviours. Lang and Rayner highlight the logical absurdity of extreme ‘individual responsibility' arguments: “circumstances of free information circulation, people ‘choose' to be overweight simply because they eat too much and do too little... In fact, such propositions are deeply flawed... Population weight gain is occurring in conditions of growing ‘health consciousness'”. 21 Because of the difficulties individuals may have in locating relevant and useful information, and the factors that may impede their use of it, the other end of the leadership continuum involves greater action by governments. Here, regulators will intervene to create environments that encourage healthier choices, typically by making these more visible or accessible, or eliminate unhealthy choices, normally by removing their availability.22 Governments have constrained choices and even coerced behaviours in several situations, particularly where these would pose serious risks to others. Thus regulations have modified environments (smokefree laws), imposed limits on behaviour (permissible blood alcohol levels for driving), restricted access to products (cold medications able to be made into pseudoephidrine), and required the adoption of new behaviours (mandatory use of cycle helmets) and the relinquishment of existing behaviours (cellphone use while driving). These examples illustrate changes that reduce third party risk to individuals and, while not all were initially widely accepted, each has achieved high levels of public acceptance and satisfactory compliance. Although the evidence indicates that regulation brings about more rapid behaviour change, critics argue that these measures reduce the role individuals play in charting their own destiny, and make them little more than “just a pawn in a societal game”.23 This may explain why governments have been more reluctant to introduce regulatory initiatives that would reduce risks individuals may pose to themselves.24 25 Framing the debate; the power of language Instead of debating the evidence relating to public health measures, recent discussions have focussed more on framing the debate than they have on analysing its premises or the likely effect of different measures. For example, policies that altered school food supply were described as ‘nanny statist', and therefore undesirable, when introduced to New Zealand schools in 2007. The media carried surprisingly little discussion about the likely benefits these policies could bring. Advertisers and marketers have always known that language exerts a powerful influence.26 It is not surprising that metaphors such as the ‘nanny state' are used to shape consumers' views on government actions, particularly when these could constrain marketers' freedoms.27 The ‘nanny state' metaphor is now widely used in attempts to discredit initiatives that propose intervening in or constraining ‘the market', such as the removal of junk food from schools. A nanny state has been equated to one governed by despots no longer satisfied with issuing regulations, but bent on acquiring autocratic powers that enable them to become ‘the food police'. Jochelson was alert to these problems when she warned of the need to recognise rhetorical strategies, which she claimed were the antithesis of logical debate: “Dismissing government intervention as nanny-statist limits debate about the possible benefits of state intervention”.28, p. 1151 The nanny state metaphor may simplify a complex political debate, but does so by distorting familiar images and impeding a detailed understanding of the claims advanced. Conclusion and recommendations Government has an obligation to act to protect the health of its citizens, both in respect of traditional threats to health, such as infectious diseases, and in response to newer threats, such as diet. We recommend that government uses allsteps on the intervention ladder where these are supported by compelling public health evidence. We recommend that health policy decisions have a clear evidence base and equity rationale, where the proposed interventions have been balanced against the freedom of individuals to act on their own account without undue influence from marketing. In exercising its health leadership for the general population and in addressing the health needs of under-served or marginalised groups, we recommend that government draws on the experience and expertise of the NGO and public health sectors as well as communities, thus ensuring responsiveness to local needs. We recommend that public health practitioners place strong emphasis on communication links with communities thereby building constituencies so that public health decision-making does not occur predominantly in the bureaucratic domain. Government, the public and civil society should actively reject debates where complex issues are over-simplified or reduced to polemical and manipulative sound bites. We recommend that government actively promote wide-ranging debates that draw on and test the available evidence.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Peter Crampton, Pro-Vice-Chancellor, Division of Health Sciences, University of Otago; Janet Hoek, Professor, Department of Marketing, University of Otago, Dunedin; Robert Beaglehole, Emeritus Professor, University of Auckland, Auckland

Acknowledgements

Correspondence

Professor Peter Crampton, Pro-Vice-Chancellor, Division of Health Sciences, University of Otago, PO Box 647, Dunedin, New Zealand. Fax +64 (03) 4795058;

Correspondence Email

Peter.Crampton@otago.ac.nz

Competing Interests

None

- World Health Organization CoSDoH. Closing the Gap in a Generation, Health Equity Through Action on the Social Determinants of Health. Geneva: World Health Organization, 2008.-- Stiglitz JE. Freefall: America, Free Markets, and the Sinking of the World Economy. New York: WW Norton, 2010.-- Sen A. Development As Freedom. New York: Anchor Books, 2000.-- Ministry of Health. Looking Upstream, Causes of death cross-classified by risk and condition New Zealand 1997. Wellington: Ministry of Health, 2004.-- Nestle M. Soft drink cpouring rights:d marketing empty calories. Public Health Reports 2000;115:308-19.-- Nestle M. Food marketing and childhood obesitya matter of policy [Perspective]. New England Journal of Medicine 2006;354:2527-28.-- Salamon L. Partners in public service: the scope and theory of government-nonprofit relations. In: Powell W, editor. The Nonprofit Sector A Research Handbook. New Haven: Yale University Press, 1987.-- Smith S, Lipsky M. Nonprofits for hire, The Welfare State in the Age of Contracting. Cambridge, Massachusetts: Harvard University Press, 1993.-- Brownell K, Warner K. The Perils of Ignoring History: Big Tobacco Played Dirty and Millions Died. How Similar Is Big Food? . Milbank Quarterly 2009;87:259-94.-- Roper B. Business political activity in New Zealand from 1990 to 2005. K 014dtuitui: New Zealand Journal of Social Sciences Online 2006;1:161-83.-- Davis P, Lichtenstein B. A viable partnership? In: Davis P, editor. Intimate Detail & Vital Statistics; Aids, Sexuality and the Social Order in New Zealand. Auckland: Auckland University Press, 1996.-- Crampton P, Dowell A, Woodward A. Third sector primary care for vulnerable populations. Social Science and Medicine 2001;53:1491-502.-- Crampton P, Starfield B. A case for government ownership of primary care services in New Zealand: weighing the arguments. International Journal of Health Services 2004;34:709-29.-- Donaldson C, Gerard K, Jan S, et al. Economics of Health Care Financing, The Visible Hand (Second Edition). Basingstoke: Palgrave Macmillan, 2005.-- McPake B, Normand C. Health Economics, An International Persective (Second Edition). Oxford: Routledge, 2008.-- Rice T. The Economics of Health Reconsidered (Second Edition). Chicago: Health Administration Press, 2002.-- Nuffield Council on Bioethics. Public Health: ethical issues. London: Nuffield Council on Bioethics, 2007.-- McRobbie H, Bullen C, Glover M, et al. New Zealand smoking cessation guidelines. New Zealand Medical Journal 2008;121(1276). http://www.nzmj.com/journal/121-1276/3117/content.pdf-- Baker M, Wilson N, Edwards R. Campylobacter infection and chicken: an update on New Zealand's largest 'common source outbreak' (letter). New Zealand Medical Journal 2007;120(1261). http://www.nzmj.com/journal/120-1261/2717/content.pdf-- Calman K. Beyond the nanny state: Stewardship and public healthBeyond the nanny state: Stewardship and public health. Public Health 2009;123:e6-e10.-- Lang T, Rayner G. Overcoming policy cacophony on obesity: An ecological public health framework for policymakers. Obesity Reviews 2007;8 (suppl 1):165-81.-- Thaler R, Sunstein C. Nudge: Improving Decisions About Health, Wealth, and Happiness. New Haven: Yale University 2008.-- Connelly J. Public health policy: Between victim blaming and the nanny state - will the third way work? Policy Studies 1999;20:51-67.-- Baron J. Medical police and the nanny state: public health versus private autonomy. Mount Sinai Journal of Medicine 2006;73:708-15.-- Kersh R, Morone J. Obesity, Courts, and the New Politics of Public Health. Journal of Health Politics Policy and Law 2005;30:839-68.-- Woodside A, Sood S, al e. When consumers and brands talk: storytelling theory and research in psychology and marketing. Pscyhology & Marketing 2008;25:97-145.-- Daube M, Stafford J, al e. No need for nanny. Tobacco Control 2008;17:426-27.-- Jochelson K. Nanny or steward? The role of government in public health. Public Health 2006;120:1149-55.-

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Our health and wellbeing are largely determined by underlying social, economic, cultural and environmental factors, and the effectiveness of health services.1 Improving health equitably requires strong leadership from all relevant sectors to encourage (nudge) individuals and groups to make healthy choices. Although this leadership comes primarily from government, with much of it expressed through the Ministry of Health, it also comes from other stakeholders such as the education, finance and transport ministries, non-governmental organisations (NGOs), commercial organisations, and the community as a whole.The perception that health is predominantly a matter of individual choice or personal responsibility presents a barrier to government leadership. Governments may be accused of interfering in individuals' freedom to choose their own behaviours, irrespective of their health impacts. No one likes authoritarian restriction of their choices, especially when the rationale for restrictions is not adequately explained. Criticism of so called ‘nanny state' intervention can resonate with governments and reduce their resolve to act in the best interests of the population, especially the most vulnerable members—children, marginalised ethnic groups, and socioeconomically deprived groups. The ‘nanny state' label inhibits the constructive debate required to reach agreement on the best way of promoting the health of all New Zealanders.The public health community must promote discussion of the balance between protecting public liberties and improving the health of the population. This debate has much in common with discussions over the desirability of free markets and government intervention in the economy; a balance of roles is usually indicated.2 In promoting debate the public health community must build strong community links so that public health interventions are perceived as being warranted.This paper analyses the role of the state and other key sectors in providing strong and balanced health leadership. It also explores how language is used to frame debates about competing models of health leadership, and makes recommendations about the leadership required to address the major health challenges facing New Zealand.The roles of the state, non-government organisations and the commercial sectorRole of the state—Most New Zealanders would agree with Nobel laureate Amartya Sen that the state has fundamental responsibilities to protect the political rights and liberties of its citizens, as well as their health and wellbeing.3 In the exercise of health leadership, these two duties may come into conflict. This issue is at the heart of public and political debates. In a vibrant democracy the boundaries of legitimate state action should be under constant scrutiny and negotiation.For example, unhealthy diets increase the risk of heart disease, stroke, cancer and diabetes, all of which are key causes of premature death in New Zealand.4 Although the role of government in promoting healthier dietary choices is debated, arguments that individuals exercise complete personal autonomy in their eating choices are flawed.Food production, marketing, and promotion exert powerful influences on individuals' choice and consumption patterns. The eating environment shapes and constrains behaviour, particularly among young people, who are more vulnerable to marketing promotions.5,6 To balance these influences, the state has an essential role in creating a context that simplifies and facilitates healthy choices.The state also has an essential role in ensuring equitable health outcomes and addressing inequities. In New Zealand this duty applies, for example, to Māori and Pacific populations, and low-income groups.Role of NGOs—In New Zealand's pluralistic democracy, the government sometimes struggles to respond fully to minority and local needs because of the political constraints imposed by the ‘median voter' (the pressure for government to respond to the apparent wishes of the majority).7(p111),8(p5) Furthermore, government policy is vulnerable to capture by powerful industry interest groups, such as the food, tobacco and alcohol industries.9,10NGOs have a special role in identifying and resisting the capture by vested interests of regulatory bodies charged with protecting the public interest. By contracting with the voluntary sector, government may achieve health gains which may not be possible through direct state intervention. New Zealand's experience with HIV/AIDS illustrates the mutual dependence and co-operation of the state and the NGO sector through the Ministry of Health, the dominant funder of the AIDS Foundation. Gay men and women initiated a community-based response to the epidemic to conduct effective education and health promotion and political lobbying of the government for funds to support the AIDS Foundation.11(p221-227)The NGO sector has a complementary role to government—it represents a vehicle for indigenous self-determination, caters for minority populations, and can experiment with policy options. Nevertheless, there are potential weaknesses of the NGO sector: it may serve as an ineffective ‘convenient solution' for government; its activities may loosen democratic accountability, and it may serve as a vehicle for disguised profit making.7(p11) A fuller account of the respective roles of government, the private for-profit sector and the private non-profit sector can be found elsewhere.12,13Role of the commercial sectorWhat role does the commercial sector have in providing public health leadership? While the ‘median voter' may constrain government's pursuit of equity, shareholders' interests and the drive to maximise profit constrain for-profit organisations. In particular, major commercial interests are generally blind to the special needs of minority groups and vulnerable populations. Further, the existence of market failures in health, and the consequent need for government corrective action via regulation, limits the role of the commercial sector in health leadership.13Economic theory argues that perfect markets permit the free exchange of goods and services between consumers and producers. Optimal outcomes depend on certainty (consumers must know what they want, and when and where they can obtain it); no externalities (unintended consequences of people's production or consumption of services); perfect knowledge (patients must know about their diagnoses and the full range of prevention or treatment options); the absence of self-interested advice from health care professionals; and the presence of numerous small producers with no market power.14(p24-28) These conditions are rarely, if ever, met in health care, thereby justifying the comprehensive government intervention that occurs in many countries.14(p24-28),15(p4816,p272)Notwithstanding problems with market failure, in some circumstances it is desirable (as with food safety), for the public health community to work with the commercial sector to promote independently monitored public health goals.When should governments intervene?We support the arguments made by the Nuffield Council on Bioethics, which describe when government intervention is justified.17 The Council's principles suggest an ‘intervention ladder' to inform government actions (Table 1). The Council notes that the higher up the ladder government intervention occurs, the stronger the evidence needs to be. Table 1. Government leadership for health—an ‘intervention ladder' Eliminate choice. Regulate to entirely eliminate choice, for example through compulsory wearing of seatbelts and cycle helmets. Restrict choice. Regulate to protect people by reducing options; for example, restricting the sale of cigarettes and alcohol to protect minors. Guide choice through disincentives. Fiscal and other disincentives can influence people not to pursue certain activities, for example imposing taxes on cigarettes, or limiting parking spaces to discourage the use of cars in inner cities. Guide choices through incentives. Regulations can guide choices by fiscal and other incentives, such as the provision of subsidised public transport and building high quality cycle lanes with cycle and pedestrian-friendly road layout to promote greater use of public and active transport. Guide choices through changing the default policy. For example, through the ABC smoking cessation programme the default interaction of New Zealand health practitioners with people now should involve specific questions about smoking and, if relevant, cessation advice.18 Enable choice. Enable individuals to change their behaviours, for example by offering participation in a ‘stop smoking' programme, building cycle lanes, or providing free fruit in schools. Provide information. Inform and educate the public, for example as part of campaigns to encourage people to walk more or eat five portions of fruit and vegetables per day. Do nothing or simply monitor the situation as was the case for many years with campylobacter infection sourced from chicken.19 Adapted from: Nuffield Council on Bioethics (2007). Public Health: ethical issues. London, Nuffield Council on Bioethics. Deconstructing ‘nanny state' language As Table 1 makes clear, health leadership may take many forms; ranging from observation and monitoring at one end, to restriction and elimination of choices at the other.20 The former options rely on personal responsibility and assume individuals acquire and assess information, apply it to their own circumstances, and make a decision about how they will act. However, this presumes that people have free access to easily understood information, understand the longer-term consequences of competing actions, and are willing to trade short term benefits off against future costs. Furthermore, it assumes information will be sufficiently powerful to outweigh other factors, such as marketing incentives, that discourage healthier behaviours. Lang and Rayner highlight the logical absurdity of extreme ‘individual responsibility' arguments: “circumstances of free information circulation, people ‘choose' to be overweight simply because they eat too much and do too little... In fact, such propositions are deeply flawed... Population weight gain is occurring in conditions of growing ‘health consciousness'”. 21 Because of the difficulties individuals may have in locating relevant and useful information, and the factors that may impede their use of it, the other end of the leadership continuum involves greater action by governments. Here, regulators will intervene to create environments that encourage healthier choices, typically by making these more visible or accessible, or eliminate unhealthy choices, normally by removing their availability.22 Governments have constrained choices and even coerced behaviours in several situations, particularly where these would pose serious risks to others. Thus regulations have modified environments (smokefree laws), imposed limits on behaviour (permissible blood alcohol levels for driving), restricted access to products (cold medications able to be made into pseudoephidrine), and required the adoption of new behaviours (mandatory use of cycle helmets) and the relinquishment of existing behaviours (cellphone use while driving). These examples illustrate changes that reduce third party risk to individuals and, while not all were initially widely accepted, each has achieved high levels of public acceptance and satisfactory compliance. Although the evidence indicates that regulation brings about more rapid behaviour change, critics argue that these measures reduce the role individuals play in charting their own destiny, and make them little more than “just a pawn in a societal game”.23 This may explain why governments have been more reluctant to introduce regulatory initiatives that would reduce risks individuals may pose to themselves.24 25 Framing the debate; the power of language Instead of debating the evidence relating to public health measures, recent discussions have focussed more on framing the debate than they have on analysing its premises or the likely effect of different measures. For example, policies that altered school food supply were described as ‘nanny statist', and therefore undesirable, when introduced to New Zealand schools in 2007. The media carried surprisingly little discussion about the likely benefits these policies could bring. Advertisers and marketers have always known that language exerts a powerful influence.26 It is not surprising that metaphors such as the ‘nanny state' are used to shape consumers' views on government actions, particularly when these could constrain marketers' freedoms.27 The ‘nanny state' metaphor is now widely used in attempts to discredit initiatives that propose intervening in or constraining ‘the market', such as the removal of junk food from schools. A nanny state has been equated to one governed by despots no longer satisfied with issuing regulations, but bent on acquiring autocratic powers that enable them to become ‘the food police'. Jochelson was alert to these problems when she warned of the need to recognise rhetorical strategies, which she claimed were the antithesis of logical debate: “Dismissing government intervention as nanny-statist limits debate about the possible benefits of state intervention”.28, p. 1151 The nanny state metaphor may simplify a complex political debate, but does so by distorting familiar images and impeding a detailed understanding of the claims advanced. Conclusion and recommendations Government has an obligation to act to protect the health of its citizens, both in respect of traditional threats to health, such as infectious diseases, and in response to newer threats, such as diet. We recommend that government uses allsteps on the intervention ladder where these are supported by compelling public health evidence. We recommend that health policy decisions have a clear evidence base and equity rationale, where the proposed interventions have been balanced against the freedom of individuals to act on their own account without undue influence from marketing. In exercising its health leadership for the general population and in addressing the health needs of under-served or marginalised groups, we recommend that government draws on the experience and expertise of the NGO and public health sectors as well as communities, thus ensuring responsiveness to local needs. We recommend that public health practitioners place strong emphasis on communication links with communities thereby building constituencies so that public health decision-making does not occur predominantly in the bureaucratic domain. Government, the public and civil society should actively reject debates where complex issues are over-simplified or reduced to polemical and manipulative sound bites. We recommend that government actively promote wide-ranging debates that draw on and test the available evidence.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Peter Crampton, Pro-Vice-Chancellor, Division of Health Sciences, University of Otago; Janet Hoek, Professor, Department of Marketing, University of Otago, Dunedin; Robert Beaglehole, Emeritus Professor, University of Auckland, Auckland

Acknowledgements

Correspondence

Professor Peter Crampton, Pro-Vice-Chancellor, Division of Health Sciences, University of Otago, PO Box 647, Dunedin, New Zealand. Fax +64 (03) 4795058;

Correspondence Email

Peter.Crampton@otago.ac.nz

Competing Interests

None

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