Models of Prevention and the Role of Government
In addition to their differing epistemologies and technologies, the public health and medical models of prevention also differ in the ways they fit into understandings about the role of government. A challenge facing the public health model of prevention, which is not the case with the medical model, is the extent to which public health interventions are perceived to occasionally clash with American societal norms and values, including arguments about the role of government and health as a public or private good. Such clashes can result from the public health model’s typical policy tools, the nature of its interventions, and the topics it addresses.
Public health prevention involves policy changes at various levels of government. The policy tools used to implement prevention policies range from varying degrees of coercion, like regulations and sanctions, to varying degrees of non-coercion, like benefits, inducements, and hortatory tools.21 Critics of the public health model complain about both ends of the coercion/non-coercion continuum for reasons ranging from questioning the role of government to involve itself in individuals’ lifestyle decisions to using public funds to make physical environments safe for physical activity.
Since public health prevention targets individuals’ behaviors, environmental change, and the social determinants of health, it is inherently linked to politically sensitive topics. The nature of public health prevention disrupts societal and institutional inertia, at times confronts and conflicts with individual choice, and can be criticized by opponents as expansions of the “nanny state.” The topics addressed by public health prevention also can prick social norms and values, like needle exchange programs for drug users22 and a number of safe sex/sex education initiatives for teens and adolescents.
A political argument that serves as an umbrella for these issues is to what extent health is a private or public issue. If one were to use Stone’s market and polis models,23 one would find that the economic rational decision-making market individual sees health as the consequence of individuals’ decisions and behaviors. Meanwhile, from the political decision-making polis, health is the consequence of history, culture, geography, education, economics, policy, and opportunity. However, even the libertarian market individuals’ health becomes a collective, public issue when individuals’ poor health and health choices result in accumulative harms, such as the meteoric rise in preventable chronic disease and chronic diseases’ impacts on healthcare spending; structural harms, such as increased system-wide costs for medical care due to paying for indigent care; and harm to a group that results from harm to individuals, as evidenced by the opportunity costs borne by specific groups who experience significant health disparities.24
However, these arguments are not foundational to the prevention models themselves. They have more to do with the strategies and rhetoric policy actors use within the policy subsystem for advocating their particular points-of-view and interests. These arguments are also helpful for winning over policy actors and policymakers who lack the expertise to understand the technicalities of the subsystem discourse.