Paternalism and Health: How Far Should We Go?

May 16, 2011

Mayor Bloomberg of New York made headlines when he decided to take on the soda industry (ok, I know, my New York roots are showing – pop for those of you from the Midwest!). Specifically, Mr. Bloomberg is seeking a federal waiver in the food stamp program (now called SNAP – supplemental nutrition assistance program) to ban the purchase of sugary beverages because of their contribution to diabetes and obesity.

Under the mayor’s proposal, there would be a “ban [on] the use of food stamps for carbonated and non-carbonated beverages that are sweetened with sugar or high-fructose corn syrup and have more than 10 calories per eight-ounce serving.” Mr. Bloomberg is proposing a two-year experiment that would test this change to see if it can make an impact on obesity and diabetes among the food stamp eligible population.

This issue brings out folks on all sides of critical questions about health, ethics, poverty, individual rights, etc. – and makes for strange bed fellows in some cases. It is, indeed, a very important policy debate and the kind of debate we should be having more of because it focuses on the proper role for government in public health.

Surprisingly, in a recent poll, 57 percent of Americans said that the federal government should take a stronger role in reducing childhood obesity. But is eliminating food stamp funding for sugary drinks what the American public had in mind? That is less clear.

Mayor Bloomberg and others who support the ban argue that between $75 and $135 million in food stamps is spent on sugar-sweetened drinks in New York City each year. They also assert that consumption of sugar-sweetened beverages is the single biggest contributor to obesity. The mayor has allies in the public health community who note the federal government is, indeed, spending hundreds of millions nationally supporting the purchase of sugary drinks that have been linked to obesity (saying that alone is the single biggest contributor to obesity is a much more debatable statement).

Of course, the soft drink industry is opposed to this change – that is to be expected.

But other groups are opposed as well. Most notably, the Congressional Black Caucus raised particular concerns about the discriminatory effect of singling out the food stamp population for this change.

Our history of using social policy to achieve health outcomes is not especially good. One has only to think of prohibition and what a failure it was at achieving its goals to question whether banning funding for these drinks is an approach that will really work to achieve the laudable outcomes articulated by Mayor Bloomberg.

But the more compelling argument against the mayor’s approach can be made by looking at a different approach taken to a similar issue: smoking.

The quest (not yet over) to reduce or eliminate smoking has been a more than 10 year effort to change public opinion – and ultimately, behavior – around smoking. The effort to reduce tobacco use in this country has been multifaceted and actually, relatively egalitarian. While the cost of cigarette tax increases aimed at reducing smoking rates may have been disproportionately borne by the poor, it was not uniquely directed at them.

Like smoking, obesity is not an epidemic unique to the poor. To aim a policy at them and them alone seems sure to result in a backlash of some kind. People always figure out ways around policies that are intended to limit behavior.

Instead, a much more reasoned (and likely more effective) strategy would pursue a systemic, multidimensional approach involving communities, schools, and public education, along with broad-based approaches to food and nutrition policy including advertising and taxation. Targeting one segment of society and one particular public program could unintentionally stymy this kind of broader-based effort.

I hope the Agriculture Department gives long and deep thought to these possible consequences as it considers the approach suggested by Mayor Bloomberg.