Point/Counterpoint: Nanny State vs. Government Innovation
No to a Nanny State
by Victor Strecher
Lately I've been hearing the term "nanny state" a lot. People seem increasingly worried about government doing everything for us. In fairness to government efforts, imagine what would have happened if people had cried, "Nanny state! Nanny state! We want our pump handles!" back in 1854, when John Snow identified a public water pump as the source of a cholera outbreak in London. Obviously, government intervention makes a lot of sense when it comes to issues like communicable disease. And it's much easier to be healthy when you're in an environment that has sidewalks and bike paths and parks—which are typically done by governments. I think we all understand and appreciate that.
However, I don't believe government intervention alone is enough to create a healthy society. The private sector has a strong role to play in developing new and innovative options for preventing disease and maintaining health. Individuals, too, have an important role to play through self-control and personal responsibility.
So it's a three-way balance, and in the United States we haven't yet figured out how to get that balance right. Our current political environment seems to be moving toward an "every man for himself" approach to living, and I truly disagree with that. But the opposite scenario—where we end up lacking the ability to make our own decisions to improve our health—is equally scary. Partly because of the prevalence of lawsuits, we've become an overly protectionist, overly scared society that in some instances creates the need for regulation where it doesn't need to exist.
We should ask ourselves, philosophically, if we ought to be prohibiting an adult from buying a Big Gulp® at a 7-Eleven®. In the greater scheme of things, I'm not sure that's healthy. There's a strong argument to be made for a baseline level of governmental protection—with automobiles, pollution, and other such issues. But in terms of trying to regulate people's behavior for non-addicting substances, for example, I think we have to be careful. It's more important, in my opinion, to inform the public that the Big Gulp® has over a half-a-cup of sugar in it and let them make their own decisions about whether to buy it. It's far more "healthy," in other words, to live in an environment that supports self-determination by allowing people to create their own values and purposes (not ours), and to fulfill their own lives, than to constantly try to protect them from themselves. If we do the latter, we'll wind up with a nanny state.
Public health bears some of the blame. As a profession, we put far too much emphasis on avoiding death as opposed to living life. Just look at one of our leading journals, Morbidity and Mortality Weekly. Mark Twain said that "the fear of death follows from a fear of life." I'd like to see our profession consider ways to help people live more fulfilling lives. We could, for example, encourage the development of core values that promote resilience and strength along life's rocky road.
One way to promote new ways of thinking about public health is for our field to collaborate with the private sector, which I have found to be far more innovative and nimble than the public sector. Universities can show the way. Our new innovation efforts at the School of Public Health are aimed at fostering a better understanding of the private sector and developing social-entrepreneurial initiatives that can reach a broad spectrum of populations, including the poor and underserved. It's critical that those of us in public health gain a deep understanding of how the private sector works and develop real public-private collaborations that can have a positive impact on society. My own experience developing HealthMedia—now the flagship enterprise of Johnson & Johnson's wellness and prevention initiative—has taught me that public-private partnerships can sometimes reach more people than the most well-intentioned government efforts.
In fact, an M.B.A. may be just as important as an M.P.H. when it comes to solving the world's health problems. At SPH, one of our key University of Michigan collaborations is with the Ross School of Business. As we work together to balance the roles of government, the private sector, and individuals in improving the public's health, we need to pursue new and innovative alignments—with professionals who know how to identify investment capital, set up businesses, create supply-chains, and identify naturally entrepreneurial individuals and communities (which I have found to exist throughout the developing world); with governments who support the seeding and cultivation of innovation and entrepreneurial development; and with individuals who accept responsibility for their own behavior and realize that true health comes from self-determination.
Victor Strecher, Ph.D., is professor and director for innovation and social entrepreneurship at U-M SPH, and director of both the Health Media Research Laboratory and Cancer Prevention and Control in the U-M Comprehensive Cancer Center. He is the chair and founder of HealthMedia, Inc.
Few would argue that the government's primary role in public health is to protect people from themselves (the "nanny state") or that government alone should be responsible for a healthy society. Yet we also need to recognize that there are many issues in which the private sector does not have the legal authority or the financial interest to intervene. And it is in these instances where some innovative and promising public/private collaborations are occurring.
Yes to Government Innovation
by Paula Lantz
From a policy perspective, we primarily think about the need for government action when the private market isn't working or when it creates unacceptable inequities in society. It is here that government needs to intervene, and local, state, and federal governments have many policy levers in addition to paternalistic prohibitions on behavior. One such lever is taxation. For example, state and federal cigarette taxes reduce demand and are considered an essential component of a comprehensive tobacco control policy.
Another important lever is to provide information and education, as in the federal government's "Back to Sleep" campaign to prevent Sudden Infant Death Syndrome. This campaign is a good example of an intervention the government "made" itself in-house. It is often the case, however, that the most innovative and effective public health interventions are ones that government "buys" from the private sector via contracts and grants. A great example of this is the highly successful "truth campaign"—aimed at preventing tobacco use among youth—which was designed by contracting with private-sector experts in marketing and mass communications.
Although many private businesses share the core values we prize in public health, the reality is that private industry has the primary goal of making money. This creates disincentives to invest in high-risk enterprises that may improve public health but might not pay off. It is here that government can promote innovation by incentivizing or subsidizing the risks inherent in the design of new and innovative products, programs, and services. A great example of this is National Institutes of Health research grants. Case in point: much of the research and development that preceded Professor Victor Strecher's HealthMedia innovations and current collaborations with the private sector was funded by government/NIH research awards.
Of course, taxpayers have a low threshold for risky, low-return investments with their hard-earned dollars. We see this in the recent criticisms of the Obama administration's investments in renewable energy technology.
Obviously, the government should not be making outlandishly risky investments with taxpayer money. Nonetheless, there are areas of public health where the private sector is simply not going to be interested. Consider the new Health Care Innovation Awards program at the Center for Medicare and Medicaid Services. Since the goal of this program is to design and test innovations for saving money in large public insurance programs without compromising care, the government must provide the incentives for entrepreneurial thinking and innovation.
As another example, a huge problem is the lack of full-service grocery stores in urban areas like Detroit. This is a market failure: larger stores cannot generate enough consistent income to stay in business. There are things that the government can do to address this problem, like subsidizing new businesses with low-interest loans or changing zoning laws.
New York City has come under fire lately (and rightly so) because of an enacted ban on super-sized, super-sweet beverages and a proposed ban on table salt. At the same time, the NYC health department has implemented some innovations that have redesigned government policies originally used to successfully fight infectious diseases for chronic disease prevention and control. This includes a 2005 mandate that NYC laboratories report elevated hemoglobin A1C tests to the health department, creating the nation's first population-based registry to track blood sugar levels among people with diabetes. This represents a great collaboration between government and health care providers: public health staff analyze and report information back to providers, and assist in advising people with severely elevated A1C levels to seek medical care. Public health staff also apply state-of-the-art geocoding and mapping techniques to registry data to identify "hot spots" of uncontrolled diabetes. This helps identify neighborhoods to target with "upstream" community-based interventions.
It is easy to criticize the government for intruding into people's private lives and choices for the sake of public health. However, the government's role in promoting and protecting health goes far beyond the headlines and rhetoric about the nanny state. It is with these other policy levers that we can point to significant impacts on public health, and we can also see the potential for additional fruitful and innovative collaborations with the private sector.
Paula Lantz, Ph.D., is professor and chair of the Department of Health Policy at George Washington University in Washington, D.C. She served on the U-M SPH faculty from 1996 to 2011 and chaired the Department of Health Management and Policy from 2005 to 2011.