Study finds high support for public health interventions, few worries about encroaching ‘nanny state’
by Kim Krisberg
When it comes to public health law, it seems the least coercive path may also be the one of least resistance.
In a new study published this month in Health Affairs, researchers found that the public does, indeed, support legal interventions aimed at curbing noncommunicable diseases such as diabetes, heart disease and obesity. However, they’re more likely to support interventions that create the conditions that help people make the healthy choice on their own. They’re less likely to back laws and regulations perceived as infringing on individual liberties. It’s a delicate balance, but encouraging news for public health workers.
“Public health should feel emboldened by this study,” said co-author Michelle Mello, director of the Program in Law and Public Health at the Harvard School of Public Health. “There is public support for the enterprise they’ve embarked on…the question is how to do it in a way that capitalizes on (that support).”
Mello and her co-author Stephanie Morain examined public perceptions of what they called the “new frontier” in public health law — legal interventions focused on human behavior to prevent noncommunicable disease. Such “new frontier” interventions include reducing trans fat consumption, increasing cigarette taxes or implementing school-based efforts to identify overweight or obese children. The study notes that in 2000, the nation’s three leading causes of death were tobacco use, poor diet and physical inactivity, and alcohol consumption. More than 75 percent of U.S. health care costs are related to preventable chronic conditions. Mello and Morain write:
The controversy calls into question the public’s willingness to view as legitimate uses of the power of the state any new-frontier interventions that attempt to use the law to prevent noncommunicable disease by influencing personal health behavior. Securing and maintaining legitimacy — that is, the public belief that officials have moral and legal authority to address the problem of noncommunicable disease and its behavioral underpinnings — is critically important because that authority affects people’s willingness to support and comply with public policies. Compliance with such interventions, in turn, is a critical determinant of the extent to which the policies will achieve their objectives.
“We were really interested in the novel efforts by public health departments to make new entrees into the chronic disease realm,” Mello told me. “This isn’t a totally new realm (for public health), but there is a new emphasis.”
In surveying more than 1,800 U.S. adults, the two researchers found high support for government action on “new frontier” public health efforts. For example, more than 80 percent of respondents supported government action to prevent cancer, heart disease, childhood obesity and to help people control their diabetes. An even higher proportion of respondents said the government had a responsibility to address more traditional public health issues, such as providing vaccines and preventing food-borne illness. Respondents also had positive opinions of public health agencies, especially the Centers for Disease Control and Prevention and state and local health officials.
A particularly interesting, but probably not surprising, finding was dramatically lower levels of support for measures believed to be individually coercive. For example, policies to make fresh fruits and vegetables more affordable or to post calorie counts received supports of 83.6 percent and 80.8 percent, respectively. But support for an insurance premium surcharge for obese individuals only received the support of 37.6 percent of respondents. Similarly, more than 72 percent of respondents supported providing people with free nicotine patches; only 20 percent supported allowing employers to test and fire employees for tobacco use.
“These findings suggest that continuing the current focus on using law to shape health environments, instead of exerting more direct pressure on individual behavior, is a sound strategy for maximizing the legitimacy of policies,” the study authors wrote.
Engaging the public in public health
Mello told me she was surprised at the high levels of support almost all the interventions received, noting the constant warnings of encroaching nanny states and over-reaching government that tend to dominate the media. In contrast, “our study revealed a quiet majority that supports the aims of these types of interventions…actually they want the government to do more,” she said. She said she also thought that those people targeted by the interventions would be less likely to support them. But, with the exception of smokers, that wasn’t the case. People who were overweight or living with diabetes tended to welcome public health interventions.
“In terms of political feasibility…we saw a gradient in public support that matched the gradient in coercion,” said Mello, who is also a professor of law and public health in Harvard’s Department of Health Policy and Management. “As a political matter, the smoothest path is to pick interventions that aren’t choice restricting, that don’t infringe on personal liberties. The dilemma, however, is that those (interventions) might not be the most effective.”
Both Mello and Morain said engaging the public in the policymaking process could be key to public buy-in and compliance. Their study noted that the “strongest predictor among the belief measures we tested was the perception that ‘people like me’ can influence government priorities in public health.” Morain, a doctoral candidate in the ethics tracks of the Interfaculty Initiative in Health Policy at Harvard, told me that support levels ticked up when people believed the government understood their values.
“It’s really important to involve the public in priority-setting activities, to understand the values held by different populations and to be able to communicate how their values are being reflected in the policymaking process,” Morain said.
Scott Burris, director of the Public Health Law Research Program at Temple University, said the Health Affairs study is among those “exploding the myth that people don’t like public health interventions.” Referencing his own body of work, Burris said that in the last 50 years, there’s been few public health developments more important, more effective or more popular than the use of law to intervene on behaviors and environments to make people safer. For instance, he cited laws restricting tobacco use and making motor vehicles safer — “today, nobody would say we shouldn’t have laws against drunk driving or promoting seat belts,” he said.
“What’s happening now is we’re moving toward deeper causes … how health is built into our society,” Burris told me. “We’re not talking about someone crashing into a wall and being saved by an airbag — there’s that strong link between intervention and harm. …We don’t have the epidemiology yet that has convinced people that buying a Big Gulp soda is the same as smoking a cigarette.”
The food and beverage industries are formidable — as was witnessed this week when a judge struck down New York City’s law restricting certain establishments from selling sugary drinks larger than 16 ounces (the ruling will go to appeal this summer) — but they’re not unbeatable, Burris noted.
“If you take the long view and look at our public health successes and how they’ve bubbled up from all over the place…you see that we continue to have a pretty good record of beating the big money,” he said.
Luckily, people are beginning to realize that serious problems such as obesity and diabetes aren’t simply related to a person’s individual choice. It’s also the physical, organizational and social environments that shape our behaviors — “now, people are saying, ‘hold on, this isn’t just natural, it’s a logical consequence of the way we organize our communities and our society,’” said Alex Wagenaar, associate director of the Public Health Law Research Program and a professor of health outcomes and policy at the University of Florida. Wagenaar said it’s entirely conceivable that in a couple of decades, laws targeting obesity and diabetes will be as commonplace and accepted as the public health laws and regulations we take for granted today. (For example, he noted that it was a big fight to get car manufacturers to install seat belts and yet today buckling up is the norm.)
“It’s hard at the start, but it seems like we have no other choice,” Wagenaar told me. “We have to take on these issues…and use policies to shape the environment in a more healthy way.”
Mello noted that an interesting solution is to use “nudge interventions” in which choices aren’t restricted, but the choice environment is altered. For example, in a cafeteria, make the healthy food choices the first choices people see. In other words, use what we know about human decision-making tendencies to the advantage of better health, she said.
“I think we’ll see gradual changes over time,” Mello said “This all very new and it may take a generation for people to appreciate the magnitude of these health threats and to really accept concrete interventions.”
To read more about the Health Affairs study, click here.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.
If you’ve followed the link from the New York Times Magazine’s letters page, welcome to The Pump Handle! We’re a public health blog covering issues from healthcare to worker health and safety to water and sanitation; see our About page for the story behind our name. The full version of my post about Amtrak is here.
What I said in that post was that it makes sense to invest in intercity rail because intercity car and air travel might become prohibitively expensive and/or time-consuming in the future — whether due to a carbon tax, oil supply issues, traffic and air travel hassles, or something else. But Amtrak is also important as part of a system that lets people get around without cars.
Note that “letting people get around without cars” is not synonymous with “take people’s cars away.” The goal is to have multiple transportation options available, so people can take different modes in different situations. Maybe you take the bus to work, drive a car to the grocery store or day care, bike to a friend’s house, and hail a cab when you leave a restaurant at 10pm (or a party at 2am). Maybe you drive most of the time, but are glad that other options are there when your car breaks down. A system that allows people multiple choices about how to get around under different circumstances is good for public health in many ways:
- Exercise: Many people get far too little physical activity. Walking — even if only to the bus or train stop — and biking are good ways to get exercise while getting where you need to go.
- Air quality: Walking, biking, and riding public transportation mean less pollution per passenger mile traveled than solo driving.
- Safety: People who are too impaired to drive safely — due to alcohol, prescription medication, physical impairments, or an inability to put down a cell phone — are less likely to get behind the wheel and endanger themselves and the public if they have other options available.
- Equity: Car ownership is expensive, young teens can’t get licenses, and people need to stop driving when they get too old to do so safely. Safe sidewalks and good public transit allow people to get where they need to go, regardless of how young, old, or poor they are.
For cities that were planned with the assumption that single-occupancy vehicles would be the dominant form of transportation, it takes some work to allow for other modes. In the 13 years that I’ve lived in Washington, DC, the city has done a great job improving pedestrian and bicycling infrastructure and bus service, and several new subway stations have opened. Car-sharing programs make it easy to forgo car ownership, and that’s good both for individual households (who save on car-ownership expenses) and for the city (which experiences less pollution and congestion and probably fewer car crashes than it would if everyone were driving everywhere).
Forgoing car ownership is also easier if out-of-town destinations are accessible by something other than car. I appreciate being able to take Amtrak to Baltimore, Philly, and New York — and, judging by the ridership numbers on the Northeast Regional line, I’m far from alone. Amtrak is good for public health not only because it’s a lower-emission form of travel, but because it makes it feasible for people to live without a car.
Last week, CDC Director Thomas Frieden opened a press briefing by saying, “It’s not often that our scientists come to me to say that we have a very serious problem, and we need to sound an alarm.” What scientists found, and reported in CDC’s Morbidity and Mortality Weekly Report, is that a growing proportion of Enterobacteriaceae (a family of bacteria known for causing hospital-acquired infections) are resistant to carbapenems, a type of antibiotics that’s typically been the last line of attack against stubborn infections. Frieden explained why these carbapenem-resistant Enterobacteriaceae (CRE) are a “nightmare bacteria”:
They pose a triple threat. First, they’re resistant to all or nearly all antibiotics. Even some of our last-resort drugs. Second, they have high mortality rates. They kill up to half of people who get serious infections with them. And third, they can spread their resistance to other bacteria. So one form of bacteria, for example, carbapenem-resistant klebsiella, can spread the genes that destroy our last antibiotics to other bacteria, such as E. coli, and make E. coli resistant to those antibiotics also. E. coli is the most common cause of urinary tract infections in healthy people. So we only have a limited window of opportunity to stop this infection from spreading to the community and spreading to more organisms.
In the first half of 2012, CRE infections were only reported in 4.6% of US acute-care hospitals; what’s troubling is the rate of increase. We have a limited window of opportunity to stop CRE from becoming widespread and getting out into community settings. The key is for hospitals to act swiftly and implement recommendations from CDC’s CRE Toolkit. These include detecting and communicating about patients’ CRE infections; enforcing infection-control measures; and grouping patients with CRE together and reserving staff and equipment to treat them.
But an important point is that none of this is required, and none of this is funded. When the Netherlands wanted to beat back the emergence of MRSA, that country passed laws requiring every hospital to test patients before letting them in the door. (That story is told in this book.) When Israel wanted to counter KPC, which was ripping through its hospitals after arriving from the US, it created a national task force and imposed mandatory national measures for detecting and confining the infection. (That program is described in this 2011 paper.) And hospitals are on their own in figuring out how to organize and pay for CRE control. There are no reimbursements, under Medicare, for infection-control as a hospital task; and as infection-prevention physician Eli Perencevich demonstrated two years ago, the National Institutes of Health is not funding resistance-countering research.
If we don’t act now, we’re setting ourselves up for a future in which a minor surgical procedure and short hospital stay carries a high risk of catching an incurable infection — and even people who go nowhere near a hospital could pick up a deadly bacteria.
Alabama’s poultry industry produces more than one billion broiler chickens each year and accounts for 10% of the state’s economy. According to the new report Unsafe at These Speeds, this production comes at a steep price for the low-paid, hourly workers working in poultry plants.
The Southern Poverty Law Center and Alabama Appleseed interviewed 302 poultry workers from Alabama’s poultry industry and heard about grueling work that has left nearly three-fourths of them reporting significant work-related injuries or illnesses. A fast-moving processing line has small teams of workers handling more than 100 birds each minute, and debilitating musculoskeletal pain is a common problem. The report explains how dangerous conditions can persist:
But if the line seems to move at a pace designed for machines rather than people, it should come as no surprise. Plant workers, many whom are immigrants, are often treated as disposable resources by their employers. Threats of deportation and firing are frequently used to keep them silent.
But workers speaking freely outside of work describe what one called a climate of fear within these plants. It’s a world where employees are fired for work-related injuries or even for seeking medical treatment from someone other than the company nurse or doctor. In this report, they describe being discouraged from reporting work-related injuries, enduring constant pain and even choosing to urinate on themselves rather than invite the wrath of a supervisor by leaving the processing line for a restroom break.
Grueling, painful jobs with supervisors who discourage sufficient bathroom breaks generally don’t appeal to workers who have other options. After Alabama passed its extreme anti-immigration bill, HB 56, many immigrants left the state; even many with legal documents felt harassed and unwelcome. Employers who’d previously relied on immigrants have had a hard time filling jobs in poultry plants and tomato fields. But rather than improving the wages and working conditions to make these jobs more appealing, poultry plants seem to have gotten even worse. The report explains:
Many Latinos – regardless of their immigration status – apparently did choose to flee the state rather than face the racial profiling and harassment promoted by HB 56.
The lines of Alabamians wanting their jobs, however, failed to appear.
… Poultry workers say HB 56 has left processing plants understaffed as some companies choose to leave many positions unfilled. They say companies have used the new law to intimidate the remaining undocumented employees into working under even more dangerous conditions.
Francisco,* a 50-year-old Latino poultry worker in North Alabama, has seen a dramatic change since the law took effect. He said his employer has hired very few workers to replace those who fled.
Instead, HB 56 has forced each worker to process more chickens than before. The plant has even increased its line speed in the deboning area, despite the number of workers there dropping from about 42 workers per line to about 32. The few new hires are thrown into their jobs without training – a decision that makes their dangerous jobs even riskier, he said.
Francisco believes the company knows that many of its workers are undocumented and is exploiting their fear of HB 56 for profit. The company has threatened mass firings if workers cannot keep up with the faster pace, he said.
Conditions for poultry workers in Alabama and the rest of the country could get even worse if the US Department of Agriculture finalizes a proposed rule that would allow poultry plants to increase poultry-plant line speeds to 175 birds per minute (watch this animation to see how fast that is). SPLC and Alabama Appleseed conclude their report with recommendations, and the first one on the list is that USDA stop this proposed increase of maximum line speeds. They also recommend that OSHA “affirmatively regulate line speeds and the number of birds per minute each worker may be required to process” and ” issue comprehensive ergonomics regulations to reduce musculoskeletal disorders arising from repetitive motion in the poultry industry.” Read Unsafe at These Speeds for more on the problem and solutions.
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On March 12, 2003, the World Health Organization issued a global health alert for an atypical pneumonia that was soon dubbed SARS, severe acute respiratory syndrome. The coronavirus had a high fatality rate; it emerged in China’s Guangdong province and within a month affected 8,000 patients, killing 774 of them in 26 countries. Toronto was one of the cities hit hard by the disease, and ace health reporter Helen Branswell of the Canadian Press has written several pieces on ten-year anniversary of the outbreak.
In “A decade ago, SARS raced round the world; Where is it now? Will it return?” Branswell writes for the Canadian Press:
Measures taken in 2003 to contain the outbreak — isolating SARS patients and quarantining people who had been exposed to a SARS case to prevent them from exposing others — succeeded at putting out that particular fire.
“That human adapted virus, that spread all the way to Singapore, Canada and … all that, that is not circulating currently in animals or in humans,” says Malik Peiris, a microbiologist from Hong Kong whose lab was one of two to first identify the virus responsible for the explosive outbreak that killed 916 people worldwide, 44 in Canada.
“(But) you can’t be sure that SARS won’t come back.”
That’s because close relatives of the virus exist in nature. And the cascade of events that led a bat virus to spark a human disease outbreak could repeat themselves, experts warn.
In “Ten years later, SARS still haunts survivors and health-care workers,” Branswell writes that 20% of the global SARS cases and 43% of the Toronto SARS cases were healthcare workers, and some of the survivors suffer from PTSD. The report Ethics and SARS: Learning Lessons from the Toronto Experience by the working group of the University of Tonronto Joint Centre for Bioethics describes some of the strains on healthcare workers:
“Mary,” a nurse in the Intensive Care Unit, is afraid that when she goes to work she will have to care for SARS patients and may become infected. Her husband asks her to call in sick, pleading that it is her duty as the mother of three small children not to risk giving them SARS. “Mary” feels torn. She feels her primary responsibility is to do everything in her power to protect her children. At the same time, “Mary” has a strong commitment to her profession, and the family needs her income. She has studied hard to become a staff nurse, and is aware of the importance the hospital places on good attendance. Her salary is affected by calling in sick. She also wants to support her colleagues on the front lines by going to work.
For the first time in more than a generation, Toronto health care practitioners were forced to weigh serious and imminent health risks to themselves and their families against their obligation to care for the sick. This generation of clinicians had entered their profession in an era when there was little expectation of facing deadly infectious diseases that had no ready cure. Suddenly, a large number of health care workers, particularly nurses and doctors, faced tough choices about how much risk to take. They had to put their lives at risk to help others. Dozens of medical workers, most of them nurses, caught SARS during their work. The most public example of the sacrifice by a health care worker was the untimely and tragic death of Dr. Carlo Urbani, who was infected in Vietnam.
SARS imposed great stresses on health care workers. They feared contagion for themselves and their families, and being shunned by others in case they were infectious. They suffered from disrupted routines, and loss of work for those who were quarantined or were unable to work because their hospitals had cut back on admitting non-SARS cases. Many health professionals had to wear cumbersome and very uncomfortable equipment to protect themselves, causing discomfort and hampering their ability to work. This also reduced the human contact with sick and dying patients.
Hospital patients suffered, too, the report explains, as hospitals canceled surgeries and barred patients’ family members from visiting them.
In several Asian countries, travel restrictions hammered the tourism industry, disrupting families’ livelihoods and harming countries’ economic growth. Economists Jong-Wha Lee and Warwick J. McKibbin calculated that SARS cost Hong Kong 2.63 percent of GDP and China one percent.
In 2007, SARS-inspired revisions to the International Health Regulations entered into force. The IHR require all 194 WHO member states to report certain disease outbreaks to WHO (including novel influenzas) and to strengthen their surveillance and response capabilities. In an interview with Helen Branswell, WHO Director General Margaret Chan — who was Hong Kong’s director of health during the SARS outbreak — explained how global preparedness has improved since SARS:
“SARS was a very important event…. And many countries have learned from SARS…. The SARS event sort of gave them additional impetus and the sense of urgency for them to really revise the International Health Regulations.”
“…All in all, and because of the impetus coming from the SARS outbreak in 2003, countries of this organization reviewed and also renewed and also updated the IHR and all these requirements actually paved the way for countries to build their capacity and also understand the need for transparency.”
“And we have noticed that the time from event diagnosis to reporting to WHO has decreased tremendously. And the country capacity is much better than pre-SARS. It’s a long way to tell you: Yes. Because of SARS, I think the world is in a much better position to detect events.”
Global communication about disease outbreaks can only happen once a new outbreak has been identified, and that relies on local surveillance capacity. Both surveillance and response capacity can easily fall prey to budget cuts, though, as memories of past epidemics fade. The US saw a big investment in preparedness after 9/11 and the anthrax attacks, but funding has since declined. SARS’ 10-year anniversary should serve as a reminder that we won’t get a warning before the next outbreak hits, and we need to be ready.
In the Washington Post, Sari Horwitz and Lena H. Sun report that President Obama will likely nominate Thomas E. Perez to be the next Secretary of Labor, following the departure of Secretary Hilda Solis. Perez is currently assistant US attorney general for civil rights.
The article mentions work by Perez on issues important to workers’ health and safety. In 2005, Perez served as president of the Montgomery County (Maryland) Council, and one of the laws he pushed for was a domestic workers’ “bill of rights.” In 2007, Governor Martin O’Malley appointed him the state’s secretary of labor, and in that position Perez pushed to protect workers from being misclassified as independent contractors, which illegally deprives employees of unemployment and workers’ compensation insurance coverage.
In other news:
Las Vegas Sun: A new report from the National Employment Law Project finds that many employers hire undocumented workers and then use the workers’ immigration status to deny them rights that the law affords to all workers. “Many of the cases cited in the report involve workers who either were part of unionization efforts or who filed for unpaid wages or workers compensation before their employers fired them or alerted immigration authorities to their status.”
The Journal Gazette (Ft. Wayne, Indiana): A Journal Gazette investigation into the Indiana Occupational Safety and Health Administration found the agency has fewer inspectors than it used to and is inspecting fewer workplaces and issuing fewer violations. (Indiana is one of 26 states that runs its own OSHA program, rather than falling under federal OSHA’s jurisdiction.) A recent federal audit of Indiana’s program “found staffing to be a major, ongoing problem for the agency.”
In These Times: More than a dozen state legislatures have slashed funding for the agencies that enforce minimum-wage laws, which leaves victims of wage theft — many of whom earn low wages to begin with — with little recourse to recover money employers owe them.
Washington Post’s Wonkblog: With mining giant Patriot Coal having declared bankruptcy and the United Mineworkers’ pension plan facing severe funding shortfalls, thousands of retired coal miners may lose the pensions and health benefits they rely on. Senator Jay Rockefeller introduced legislation that would provide for affected retirees after meeting with West Virginia families poised to lose their benefits.
New York Times: According to Unicef, 28 million Indian children ages 6-14 are working instead of attending school, even though India now requires school attendance for children through age 14. In the northeastern state of Meghalaya, many of these children labor in unsafe coal mines.