April 25, 2006, 6:55 a.m.
Big Brother Will See You Now
Public health gets too personal.

By Elizabeth M. Whelan

Earlier this year in New York City, a public-heath regulation went into effect that set a new and very troublesome precedent, one that insinuates government agencies into personal medical matters.

In mid-January, the city began legally requiring laboratories that do medical testing to report to the Health Department the results of blood-sugar tests for city residents with diabetes — along with the names, ages, and contact information on those patients.

City officials are not only analyzing these data to assess patterns and changes in diabetes prevalence in the city, but are planning "interventions." Simply put, diabetics will soon receive letters and phone calls from city officials offering advice and counsel on how to effectively deal with their medical condition. If you wish to keep your medical data confidential, you cannot. If you want to avoid the "interventions," you can go online and fill out forms requesting that you not be contacted — that is, if you even know the program exists, and you have the sophistication and technology to access the government’s "do not contact" forms. (None of the New York City newspapers have done any in-depth coverage of this new regulation and its implications.)

Diabetes is now among the leading causes of death in the city (and nation) — and its incidence is rapidly increasing. Genetics (family history) plays a major role — blacks, Asians, and Hispanics are much more susceptible to diabetes than whites, for instance. Obesity is a major risk factor for the disease. If not managed prudently, diabetes causes kidney failure, heart attacks, strokes, and other life-threatening or debilitating illnesses. There is good reason for the city's public health establishment to be concerned.

But given that diabetes prevention (through weight control) and management (through diet planning, exercise, monitoring, and medications) are matters of personal commitment and responsibility, the disease cannot effectively be "solved" by government intervention that goes beyond educational programs.

The city’s new reporting policy represents a dramatic change in public-health and preventive-medicine strategy. Government officials have for years required reporting of various infectious diseases. For example, sexually transmitted diseases are reportable so that partners can be traced and alerted to the possibility that they too may be infected. Similarly, if a plague, such as ebola or smallpox, were to break out, we would expect government to track the disease and even to wield quarantine powers. But what those cases have in common is that the diseases in question are communicable.

The mandated reporting of blood-sugar tests is the first reporting program aimed at countering a non-communicable disease. And this may be only a first step in what is an emerging public-health policy that assigns to government the responsibility for reducing the rate of certain diseases — and obesity, after all, contributes greatly to the
toll of disease in America. Thus, we can expect that there will be similar proposals mandating reporting of serum-cholesterol levels, blood-pressure readings, and body-mass-index (BMI) scores, with subsequent "interventions" to get people to change their behavior and reduce the risk of heart attack, stroke, and the spectrum of maladies associated with obesity. And we can expect even more government rules and regulations — designed to protect us from what some in public health deem to be the modern-day "vectors" of disease, just as mosquitoes are the vector for malaria.

Along these lines, some states have recently contemplated legislative moves to ban certain food advertising, impose higher taxation on so-called "junk foods" and alcohol, and restrict the sales of soda and other foods and beverages. NYC Health Commissioner Thomas Frieden believes that government should go even further in coercing Americans
toward better health: He predicts we will have "regulations to facilitate physical activity, including point-of-service reminders at elevators and safe accessible stairwells [and] modifications of the physical environment to promote physical activity."

Some are resigned to this new regulation, arguing that if government is assigned the role of paying for health care, it is entitled to intervene to reduce the risks of disease and thus reduce the costs. But as we set forth into this brave new world of public health, some facts cannot be ignored:

The implicit assumption behind these monitoring and follow-up programs is that government can be as successful in reducing chronic disease through legislation as it was in wiping out many infectious diseases through classic public-health measures like vaccination and chlorination of water. However, there is no evidence that these new government efforts will pay off in terms of better health.

Matters of patient confidentiality and personal responsibility have been totally overlooked. It is safe to say that most Americans do not want their medical profiles to be a matter of public record. And they do not want clerks from the local health department calling them and telling them how to live their lives. Since so many of the risk factors for chronic disease involve lifestyle factors — overeating, lack of exercise, smoking, and more — the emerging health policies are blurring the distinction between public health and personal health, the former lending itself to community-wide mandates, the latter more appropriately the sphere of individual action and commitment.

In contacting diabetes patients to urge them to follow various protocols to preserve their health, the city is not only shattering the confidentiality of the physician-patient relationship but assuming that personal physicians are incapable of performing this role.

When the government's phone calls and letters nagging people to eat better, quit smoking, and be more physically active don't work, the next phase of the war on chronic disease may be a harshly punitive one, with fines and other restrictions on those who fail to heed the health warnings. The message will be: Live a healthy life or the government will punish you.

New York City's law mandating the reporting of diabetic blood tests is a harbinger of more intrusive legislation to come — all in the name of public health. It is high time we reflect upon the difference between public and private health, critically evaluate what role the government should play in the prevention of chronic disease, and carefully assess what cost we might pay in privacy and individual freedoms as the government performs "interventions" to protect us from ourselves.

— Dr. Elizabeth M. Whelan is president of the American Council on Science and Health.