Dr. Francisco Oviedo-Gomez MD MPH, Advisor on Health Systems and Health Services, Ministry of Health of Costa Rica



The approval of tobacco control laws around the world as a consequence of the adoption of the Framework Convention on Tobacco Control ( FCTB)  has sparked fierce debate in recent years, more in particular on the role of states in enforcing health policies which aim to create mechanisms for people so that they would refrain from practicing unhealthy habits. The increasing NCD burden around the world is one of the main reasons that have made the enforcement of such policies a key debate in the early 21st century. So this debate is here to stay.

Current examples of such policies are: notification of calorie counts in restaurants, reduction of sugar level in processed beverages, reduction or elimination of salt in processed food, specific guidelines for food services in schools, increased taxes for unhealthy products, so called “nudge policies”, etc.

Many have called these actions an unacceptable intrusion of states and governments in people’s lives limiting their fundamental rights. Some compare those governments to a “nanny” who decides what is better for her (allegedly) defenceless children, who are not capable to take their own decisions and who may never be.  In this vision, people become (too) dependent on governments, with authorities taking (too many) decisions for citizens.

Some other critics are even less kind in their comparisons: for them these policies are clear steps on the road towards totalitarianism, limiting people’s fundamental rights in order to keep the control of people’s lives in the hands of the state, not only on health related matters but also in other aspects of their daily life.

With arguments like these pretty common in mainstream and social media, it does not come as a surprise that many people are scared or are having second thoughts about endorsing such kinds of policies. And to be honest, from a historic perspective, these fears are not totally unfounded.

During the 20th century many countries witnessed the failure of policies that aimed to solve social and health problems, ending up creating new and more chaotic problems. One of the best examples of this was the Prohibition in the United States: from 1920 to 1933 a nationwide ban was declared on the sale, production, importation, and transportation of alcoholic beverages.

Unfortunately one of the main outcomes of this policy was that organized crime got a major boost. Mafia groups focused on prostitution, gambling, and theft until 1920, when organized bootlegging emerged in response to Prohibition. Rather than reducing crime, Prohibition transformed some cities into battlegrounds between different bootlegging gangs.

Despite the failure of Prohibition, one can still argue in favour of enforcing restrictive health policies, by pointing out the mistakes of previous policies and taking into consideration the lessons learnt  (see also here).  The aim should be to improve the new mechanisms by adopting a human rights perspective instead of creating merely restrictions to educate “unwilling children”.

Ensuring the human right to health depends on a series of different conditions that together provide the foundation for people to claim their right.  Access to good information is one of them
-people need to be well-informed, based on the best possible scientific evidence, on health- but also providing people with the means to act upon this information, if they want to. The state has to play a role in both.

In Costa Rica (see English translation here) some of the main supporters of the recent adoption of the tobacco control law were waiters and waitresses. They pointed out the constant harm suffered by them, as they were permanently exposed to a hazardous working environment in bars and clubs where (inside) smoking was allowed. Respiratory problems were a major problem among this group.

Non-smoking waiting staff , as well as waiters and waitresses who had decided to stop smoking, could not claim their right to health, since they did not have an effective tool that allowed them to work in a non-harmful environment.

We live nowadays in an information society where people can easily access information on what may harm their health, so in principle they can avoid the danger and live healthy lives, however –as the case of waitressing workers in Costa Rica shows, very often people need more than just access to information to make an effective and actual change in their lives.

Any starving person living on a fixed income will not think twice at lunchtime, when considering whether to spend 8 US$ on a “healthy” salad and a bottle of water or just 3US$ for a “high-calorie” meal of a hamburger, French fries and soda.

If we have learnt something from failed experiences in the past like the prohibition period, it is that the answer does not lie in declaring tobacco products illegal – or French fries for that matter-, but in creating the necessary conditions so that people may not only take informed decisions, but can live and work in an environment in which these decisions can come true.

Social changes are never easy and sometimes they are not welcomed at all at first, especially if they imply some kind of restrictions. However, if their justification is found in the necessity to protect vulnerable or unprotected groups and the mechanisms to enforce the changes are reasonable and well oriented, in time the change may become accepted as something logical and even basic. Slavery is a case in point.

Just to show you another example of what I am referring to: in 1872 the British Parliament adopted the “Licensing Act” which restricted the opening hours for pubs and prohibited children from drinking spirits in a pub. The drink trade regarded this Act as an attack on private property. Liberal thinkers felt they needed to protect the “liberty of a few against the power of the many” and so considered it better that “England should be free rather than… compulsorily sober”. Supporters of the Act replied that “drunken freedom” was not exactly “liberty”.

Nowadays, I think no one would argue with the importance of not letting children drink alcohol, we consider it just ‘common sense’ now. Sadly, for many health policies currently under discussion, that is not always so clear to many people. But maybe it is just a matter of time and in a few decades, these policies will seem to us as reasonable as we consider the 1872 policy now. In the meantime we should try to orient our policies so that they not just prevent people from doing “bad things” but rather encourage them – not force – to take the right choices.

A scholar once said that “freedom is not the right of just doing what we want, but the right of being able to choose and doing what is correct”. If we, as a society, through our governments, do not make sure that we have the tools and mechanisms to assert our fundamental rights we are not effectively protecting our freedom. Whether informed people then make the “correct” health choices is up to them. As they say in English: ‘You can lead a horse to water but you cannot make it drink’. Which is fair enough.

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