Commentary: silent prevention
Authors: Nicholas J Wald
Journal: BMJ (2004)

Oakley and Johnston correctly criticise Britain's failure to fortify flour with folic acid. But the interventionist principle in nutrition and other areas of public health goes beyond folate. Contrary to current perception, the key to effective public health is not individual choice but collective action linked to public trust in its value.

Most of the main determinants of health vary little among people in a community. The scope for individuals to choose healthy and safe foods, drinks, transport, or buildings is limited; the similarities in exposure are greater than the potential differences. To differ significantly from the collective norm we would have to isolate ourselves from the mainstream of society. It is glib and disingenuous to say that we are all consumers exercising choices, when most of the options are essentially similar. For example, most people in developed countries consume about 35% of their energy as fat, about 10 g/day of salt, and about 0.2 mg/day of folate, and nearly everyone is exposed to the risks of road injuries.

The chief merit of the increasingly popular convenience foods is their convenience. Individuals have little influence over their composition. Even foods that are described as being healthy can be high in sugar and salt, counterbalancing any benefit from added micronutrients, such as folic acid. But discouraging the use of convenience foods is not practical; we need collective action to reduce the amounts of salt, sugar, and saturated fat in foods, and a sensible policy on portion sizes in restaurants.

Of course, individuals have some choice, but for most people safety and health are minor determinants—value for money, convenience, and fashion rank much higher. Safety and health have to be part of the fabric of society, determined by experts with specialist knowledge, and translated into policies by governments, acting on our behalf. For years we have unquestioningly accepted the addition of iodide to table salt, to prevent thyroid disease; the prevention is silent. Charges of paternalism and pejorative labels such as “nanny state,” with the false innuendo that we are being controlled against our wishes, are unhelpful because effective public health needs to be integrated into the infrastructure of society. We depend on governments and professionals to ensure that our lives are as healthy and as free as possible. Governments have the main responsibility and authority for maintaining public health, through education, regulation, legislation, and taxation. Not all decisions will be right, but it is not hard to ensure that most are and, given new knowledge, to correct those that are not.

An advisory role is not enough. Public health in countries such as Britain needs a stronger executive role, relatively free of short term political considerations. Watching our children (and ourselves) becoming overweight and claiming that it is all about choice is a denial of everything that public health and preventive medicine is about, and a denial of what makes a society civilised and worth belonging to. Public health and individual choice can flourish together, but the former should not be driven by the latter.