Thursday, May 04, 2006

IN MY VIEW: Education and Persuasion versus Coercion as Public Health Approaches

In our introductory Social and Behavioral Sciences course at the School of Public Health, we teach students that there are 3 basic strategies to intervene to address public health problems.

First is a rational-empirical strategy, which basically means education directed at trying to encourage people to change their behavior.

Second is a normative-re-educative approach, which refers to changing social norms to support healthier behaviors. In essence, you are using tools to try to persuade people to adopt a certain health behavior.

Third is the power-coercive approach, which refers to using the law to mandate certain behavior.

We teach students that the type of approach which is most appropriate to deal with a particular public health problem (and it may be a combination of approaches) depends on the particular situation.

In most situations, the education and persuasion strategies are appropriate. But there are some cases in which a power-coercive approach (i.e., a legislated solution) may be necessary and appropriate.

The big question, of course, is where do you draw the line? How do you know when coercing health behavior is appropriate, as opposed to simply trying to educate people or trying to persuade them to engage in a healthy behavior?

It is difficult to articulate a clear set of criteria that would dictate to us an appropriate answer to this question.

Instead, I think we need to deal with it more like the way Justice Potter Stewart dealt with trying to define pornography. It's difficult to define the precise limits, but we should know them when we see them.

And in the recent actions and statements of a number of prominent anti-smoking advocates and groups, I see the inappropriate use of coercion as a tool for public health promotion.

The Rest of the Story

As much as we might hate to see children harmed by secondhand smoke exposure, a coercive approach to the problem of smoking in the home is not appropriate. It is crossing the line and we in tobacco control better learn to "know it when we see it."

Destroying parental autonomy and intruding upon the privacy of behavior in the home that does not cause severe, immediate, and inevitable harm (such as true physical, sexual, or emotional abuse) is not a price that is worth paying, despite how much we might want to reduce the prevalence of asthma, otitis media, and upper respiratory infections in children due to exposure to secondhand smoke.

Intruding upon parental autonomy and the privacy of behavior in one's own car that does not cause severe and immediate harm (such as not being restrained in a infant or child safety seat during a severe car accident) is also not a price worth paying, despite how much we want to prevent youth exposure to tobacco smoke in cars.

Similarly, refusing to hire smokers for employment represents an invasion of employee privacy into lawful behaviors in the home that have no direct bearing on job performance (for all but a job with an anti-smoking group). As much as we might like to intervene to reduce smoking prevalence in the workplace, a coercive approach is simply not an appropriate public health intervention in terms of promoting healthy behaviors among workers.

For some reason, I've noticed that in the past few months, the tobacco control movement has been adopting an increasingly vigorous and fast-advancing agenda of coercive interventions to try to control the behavior of smokers. And I'm not talking about smoking in the workplace. I'm talking about smoking in private cars or homes, or on public streets and sidewalks where secondhand smoke could easily be avoided.

I just don't like the direction the program is going.

We seem to be unsatisfied with education and persuasion and now we are going to dictate people's health behaviors for them.

What's interesting to me is that we in public health don't do this with any other health behavior that I can't think of. We don't dictate what people can and cannot eat. We don't dictate whether people have to exercise or not. We don't regulate people's blood pressure or coerce people into controlling their blood pressure adequately. We don't coerce people into engaging in various sexual health behaviors. We don't coerce parents into making sure that their children are healthy. There are no fines for parents of fat kids. There are no criminal sanctions for parents who let their kids watch hour upon hour of violent television programs. It is not prosecuted as child abuse when you take your kids to McDonalds to dinner every night. You are not excluded from applying for a job if you are fat. You are not fired from a job if your blood sugar exceeds 250. Having sex without a condom does not preclude you from being hired at the World Health Organization.

The anti-smoking movement has truly become a world of its own within the larger field of public health.

It has become a world of its own because anti-smoking groups are quickly losing the ability to draw the line between the appropriate use of education and persuasion and the use of coercion in promoting healthy individual behavior.

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