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What are the limits to health promotion?

If you could introduce just one of these health promotion schemes, which would it be?

A) In order to maximise the uptake of childhood immunisation against measles, mumps, rubella, diphtheria and pertussis you are able to change the law. From now on all parents must produce official certificates of immunisation to qualify for free education in state schools.

B) In order to protect the population’s teeth — and especially to promote the dental health of children — you can pass legislation permitting local authorities to add fluoride to the public water supply.

C) In order to reduce road accidents — especially in areas around schools — you have the power to enact laws prohibiting the use of private motor vehicles for transporting children to and from school and making the use of school buses mandatory for all children who live further than 1km from school (unless parents obtain a permit allowing their child to walk or cycle). Children who live less than 1km from school may choose to take the bus, walk or cycle.

A, B or C? Which would you choose, and why?

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My guess is that for most health promoters the choice would be between policies A and B. While not universally endorsed, these have existed in various parts of the world and attempt directly to reduce morbidity. Option C, on the other hand, has never been proposed (never mind tried), and seems to offer only the indirect prospect of disease reduction. What’s more, it violates individuals’ rights to use personal property as they see fit.

In western countries at least, banning the use of cars and taking away transport choices is likely to be met with indignation. ‘How dare health promoters interfere with daily life?’ ‘How I carry my children to school is my business.’ ‘The family car is hardly a health issue.’ The protests are inevitable. But is it really so outrageous?

Each option aims to reduce individual choice in order to bring about more health. A and B seek less disease while C aims for fewer road accidents, less pollution and reduced commuter stress. They are all paternalistic. They presume to know what is in citizens’ best interests and each — by legislating — suggests that not everyone can be trusted to go along with what is good for them.

There is a difference, but if anything it favours option C. Options A and B both have the effect of making possibly unwanted physical intervention lawful, while C is nothing more than a move towards full pedestrianisation in towns and cities — it may be inconvenient for some, but it is in the interests of most people, and the available alternatives (taking a bus, or walking or cycling along relatively car-free streets) are unlikely to be harmful. If I had to choose, I would go for C. As far as I can see any objection to it must be an objection not only to the two other options, but to most other forms of contemporary health promotion as well.

If health promoters find my answer troubling, then this is all to the good. There is a tendency for public health advocates to assume that work against disease automatically justifies the restriction of liberty, that conventional interventions never need to be re-examined, and that the achievement of better health somehow transcends politics. But ‘the battle against disease, illness and injury’ is not always a trump card.

We need to draw a consistent line — where does health matter most? And at what point do other social considerations begin to override it? At present, where it is visible at all, the line is extremely blurred. Instead of theory and clear argument health promoters have relied on government support and advertising campaigns. This is fine for those who share the same biases, so long as the method continues to work. But if the social climate changes, and political pressure begins to fail then what — other than faith and dedication to ‘the cause’ — will be left of health promotion?