Nanny states are now essential to economic health

In the late 19th and early 20th centuries, the rulers of the industrial world started to worry about the health of the people. National governments discovered that military recruits were too unfit to serve. City governments worried that slums were spreading disease. Corporations realised that poor health was reducing productivity.

Policymakers tore up the old laissez faire playbook — leave health to the individual — and generated a dizzying variety of innovative policies. Governments, starting with Bismarck’s Germany, introduced compulsory health insurance. Schools embraced “open air classrooms.” Companies created work-based football teams to encourage their employees to get fit: Arsenal was spawned by the Woolwich Royal Arsenal Factory in 1886 and West Ham by the Thames Ironworks and Shipbuilding Company, in 1895. Entrepreneurs such as John Harvey Kellogg invented health-promoting foods. Teddy Roosevelt turned the White House basement into a gym, complete with boxing ring, and created five new national parks.

It is time for today’s policymakers to treat health with the same combination of urgency and fresh thinking. In Britain and the United States, a 200-year trend for people to live longer and healthier lives is in danger of dead-ending. Everywhere obesity is swelling to epidemic proportions: A 2019 OECD study found that the cost of high obesity rates to health services globally is $990 billion a year, with obesity costing an average of 3.3% of GDP in the OECD as a whole and 5.3% in Mexico. We need to tear up the key assumptions that have governed health thinking in recent decades: that health care is about fixing broken people rather than promoting well-being; that the government’s responsibility for health care is exhausted so long as it provides services marked “health”; that nanny statism is a bad thing; and that food companies should be left to make money regardless of the costs they impose on society. We also need to launch an age of experiment in which we explore the power of a wide range of institutions to promote better health.

Some promising experiments have already begun. National health services in both Japan and South Korea have discovered the power of what management gurus call “stretch targets”: setting ambitious targets for improving health and encouraging a wide range of institutions to help reach them. Health services are also learning the power of “place-based policies” to address regions with particularly bad health outcomes. In the early 1970s, North Karelia province in Finland introduced a suite of policies — from lifestyle coaching to improved drug treatment for hypertension — to address its high rate of cardiovascular mortality. The policy was so successful, with coronary disease falling by 84% from 1972 to 2014, that it was rolled out nationally.

Governments have demonstrated the power of both taxes and labeling to improve behaviour. In 2016, Britain’s then chancellor, George Osborne, announced that he would impose a sugar tax levy on soft drinks. The result were encouraging: Soft drink producers reduced the sugar content of their drinks by an average of 35.4%, a change that may explain the stabilidation of obesity rates in the latest National Health Service annual health survey. In the same year Chile, where three-quarters of the adult population were obese, introduced a new front-of-package warning label (a black octagon) on foods that contained added sugar, sodium or added fats. The scheme was so successful that it spread across Latin America. Both Hungary and Mexico have gone even further, introducing comprehensive taxes on unhealthy food, with sales of the products subjected to the tax in Hungary falling by a quarter.

Companies are also discovering the power of “nudges” to encourage healthier behaviour among their employees. The most innovative company here is arguably  the South-Africa based insurer Discovery Ltd. Discovery has invented a health-care program, Vitality, which uses an air-miles type system to reward its customers for healthy behaviour: You can move up from one level to another and accumulate rewards that can be used on gym membership, healthy food or exotic holidays. Discovery has exported its model abroad by forming a partnership with Prudential Plc in the UK and Humana Inc in the US. Outside the health and food industries, a growing number of other companies are also using “nudges” of various sorts: subsidising gym membership, sponsoring sports activities, providing healthier snacks, though Western companies are unlikely to go as far as Japanese companies and measure the waistlines of employees to make sure they are not getting too fat. We need to go further: consolidate these changes, embrace new ones, and link the pursuit of health to the pursuit of competitiveness.

A new report on health and prosperity from the British IPPR think tank has some interesting ideas. Why not use the proceeds of food taxes to subsidise healthy foods? The central problem with diet is that healthy foods tend to be significantly more expensive than unhealthy ones. So, tax hamburgers to subsidise spinach. Why not use the purchasing power of big government departments to encourage healthy eating? Farming subsidies tend to go to agri-business rather than eco-farmers. Food in government institutions, from schools to hospitals to prisons, is often unhealthy as well as unappetising. Soldiers often regain the weight that they lose exercising by eating pre-processed meals. And why not use NHS apps to subsidise healthy foods or gym memberships? The Tesco chief executive, Ken Murphy, has floated the idea of using loyalty cards to analyse what people buy and advise them to choose other options if they are consuming too much salt or fat. The NHS could piggyback on this technology.

A more ambitious approach to health care will encounter powerful resistance. Food companies are masters of pretending to be responsible citizens while fighting for their short-term interests: Kentucky Fried Chicken has launched a legal challenge against 43 councils in England over planning policies to restrict food takeaways near schools. And the cry of “nanny statism” is a powerful one — particularly when the state starts to inspect your shopping basket. Yet far more companies have an interest in improving the health of their workers than do in stuffing them with salt and fat. And more people support aggressive health-intervention, such as taxing junk food, than worry about nanny statism.

Food and drink companies show no compunction about using AI-enabled nudging to sell their wares. Why should governments disarm themselves? The late Victorians and Edwardians succeeded in laying the foundations of a century of improved health because they understood that health is not only an individual good but also a collective one, and not only a nice thing to have but also a tool of national competitiveness. We need to learn the same lessons.

Adrian Wooldridge, Tribune News Service