EDITORIAL
Health promotion paradoxes,
antinomies and conundrums
If you turn the light quickly enough you can see
what the dark looks like.
— Hughes and Brecht, Vicious Circles and
Infinity: A Panoply of Paradoxes.
The importance of paradoxes
• Paradox—a person or thing that seems to be
full of contradictions.
• Antinomy—the opposition of one law, rule or
principle to another. A contradiction between
two principles, conclusions or inferences which
seem equally logical, reasonable or necessary.
• Conundrum—any puzzling problem.
(Barnhart and Bamhart, 1989)
It is obvious to note that few of us in health
education and health promotion were attracted to
the profession because of anticipated economic
rewards. Rather, most of us chose this profession
from a desire to be of service. We define our
mission as helping to reduce current and future
pain and suffering through assisting individuals,
communities and broader collectives to address
individual and social factors that contribute to
health problems. However, on occasion, despite the
best intentions, our efforts may have unanticipated,
negative consequences.
Negative consequences from health education
and health promotion programs may arise from a
variety of causes, including poorly designed and
implemented interventions, or when programs'
underlying assumptions and models of causality
are not appropriate for the setting or the problem
being addressed. Negative consequences may also
occur when programs attempt to accomplish contradictory goals, such as increasing awareness of
health problems without exacerbating the extent
of the 'worried well' (Becker, 1993) or interventions that are prevention-oriented and designed to
reduce future costs, such as cholesterol screening,
that may increase the utilization of health services
and health costs. In addition, negative con-
© Oxford University Press
sequences may arise when interventions highlight
conflicts between deeply and widely held social
values, such as conflicts between autonomy and
the public good, as in laws that mandate the use
of seat belts or motorcycle helmets.
One approach to reducing negative, undesired,
consequences is to collect information on programs
with such outcomes in order to identify programmatic or contextual factors that produce the negative effects. Another approach is to focus on the
logic and philosophical underpinnings of programs
in order to identify potential areas of conflict with
widely and deeply held values. It is this latter
approach that we are taking in this editorial.
The word paradox may be used in varying ways,
but central to the idea of a paradox is the idea
of contradiction. A paradox starts with a set of
reasonable premises from which a conclusion is
drawn. The conclusion, however, seems to undermine the premises, or it may seem absurd or wrong
(Poundstone, 1988). It is the apparent contradiction
between premises and conclusions—or in the case
of health promotion, the contradictions between
our desired goals and unintended outcomes—that
has captured the imagination of philosophers, artists and mathematicians - throughout history, and
more recently has attracted the attention of
behavioral scientists. Paradoxes provoke us into
questioning the logical relationships between our
taken-for-granted assumptions and our actions
(Poundstone, 1988) or the moral credence of the
values associated with a particular outcome
(Rappaport, 1981). ,
In a presidential address to community psychologists 15 years ago, Julian Rappoport (1981) discussed In Praise of Paradox: A Social Policy of
Empowerment over Prevention. In his talk, he
identified the importance of professional recognition and discussion of the inherent contradictions
in community psychology. Careful discussion of
paradoxes and antinomies can help us to recognize
and articulate our assumptions and values, and
may increase our awareness and understanding
of the contradictions between our intentions and
results. They remind iis of the trade-offs we must
frequently make between core values, such as our
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concept of the public good and individual freedom.
Discussion of paradoxes may also help us identify
situations that are apparent, but not real, paradoxes.
Paradoxes differ from antinomies, in that paradoxes contain apparent contradictions while antinomies are contradictions between two equally
binding laws. We face an antinomy when the
adoption of a certain strategy (e.g. regulation),
which is associated with certain values (e.g. efficacy and the public good), constrains other values
of equal importance (e.g. autonomy). The resulting
paradox of trying to do what is right, but in doing
so inevitably doing something that is wrong, helps
us realize that when we aim to maximize one value
in our interventions, it may be at the expense of
another. According to Rappaport (1981, p. 3), the
action part of our job is to confront the discovered
paradoxes by pushing them in the ignored direction.
That is, we need to pay attention to both sides in
the value conflict.
There are also situations that appear to be
paradoxes, but are not. In such situations, the
premises, or implicit assumptions, are erroneous
or do not take into account additional factors. In
the case of community interventions, paradoxical
outcomes might occur when a program fails to use
strategies that could have contributed to a more
positive solution. An example would be where
local attempts to regulate exposure to passive
tobacco smoke through restrictions on smoking in
public places result in state laws that are more
permissive than local laws and that prohibit more
strict local laws. These situations do not necessarily
involve true paradoxes. Our job, therefore, is to
examine the validity or comprehensiveness of the
assumptions implicit in interventions and the extent
to which the strategies address actual causes of
the problem (Salmon, 1989). Such examinations
help us identify situations presenting true contradictions, which are conundrums, compared with
situations that require a broader definition of the
problem and multiple level solutions. Returning
to the example of regulations governing tobacco
smoke in public places, paradoxes may be avoided
by assuring that we have broad community support
for the policies we attempt to pass and implement.
Given the current anti-government and antiregulation sentiments, this may be an appropriate
time for reflection on, and perhaps affirmation
of, some of our core professional values. In the
following sections we reflect on some of the
paradoxes, antinomies and conundrums that have
been raised in the literature. These include paradoxes associated with information dissemination,
the health gap, prevention, the Tragedy of the
Commons and increased demand. Obviously, there
are additional paradoxes that we do not have the
space or time to address in this brief editorial.
Perhaps we will be able to address some of the
additional paradoxes, antinomies and conundrums
in a subsequent article.
Paradoxes, antinomies and
conundrums
The information dissemination paradox
77if more information about disease prevention
and health promotion is disseminated, the more
people might doubt it.
Health promotion and disease prevention messages
are quickly and widely disseminated through the
national and local media. Much of the time, the
general public learns of new study results at the
same time as health professionals. The problem
with this is that the limitations of the studies are
rarely covered and a single study which may never
be replicated may get as much or more attention
as a scientifically sound study that builds on
previous findings. Although on the surface it seems
like more health information would be better, a
substantial amount of it is contradictory, with new
studies refuting previous recommendations and
different groups making different health-related
claims. This might be one of the reasons people
often attribute low credibility to medical information sources, are skeptical about following health
promotion messages and are confused about health
information, which appears to change from one
day to another (Miller, 1990; Barr et aL, 1992;
Kolata, 1995). People may feel they know less
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about health-related issues, when their knowledge
has actually increased. Using data from a national
sample conducted by the National Center for Health
Statistics, researchers note that while public knowledge of AIDS issues has increased, people's selfassessment of their knowledge in 1990 has
decreased from 1989 (Hardy, 1991). This is at the
same time that a large national public information
campaign was launched by the federal government
and stories in the mass media greatly increased
(Singer et al, 1991). Further, people often do not
trust the health information they receive (Allard,
1989; Freudenberg, 1990; Barr et al., 1992), a
situation that is especially true among AfricanAmericans (Herek and Capitanio, 1993) and
Hispanics (Dusenbury et al, 1994).
Providing more and more health information,
therefore, is not necessarily health promoting and
might in fact bring about opposite outcomes—a
public that is saturated with health messages and
confused and distrusting. Public responses to mass
media messages might be the opposite of what the
senders of the message had intended. For example,
while it seemed logical that if people are told they
do not have to worry about certain health risks
(e.g. getting infected by HIV through a health
worker), die simple act of mentioning it may start
them worrying. The more the media raises the
topic the more concerned the audience tends to be,
regardless of the content of the message. This
phenomenon was found in the context of controversial technology (Mazur, 1981), but can be applied
to the topic of AIDS and other issues that raise
public anxieties (Allard, 1989; Barr et al, 1992).
In addition, people consistently respond that they
do not believe the information they are getting is
accurate or complete (Herek and Capitanio, 1993).
The situation is paradoxical. Our conceptual
approaches for health interventions call for
information dissemination and for providing the
public with a reliable knowledge base. Our
attempts, though, might defeat the purpose and
create a backlash for two reasons. First, the more
we try to point out the limitations of incorrect
information, the more people will pay attention to
it. Second, the more people know and the more
we saturate people with health messages, the less
people will think they know and they may have
less confidence in the information they receive
(Hughes and Brecht, 1975). This paradox leads us
to ask several questions: should we provide the
public with less information, but risk not refuting
competing misconceptions and misinformation?
Should we provide a great amount of information,
but risk saturating people with an overload of
messages? Finally, are we presented here with an
unsolvable problem, a conundrum?
The health gap paradox
Interventions that aim to promote the health of
populations can result in enlarging the gap
between those who are more economically
advantaged and those who are less.
Campaigns that aim to promote the health of the
population and adopt mass media strategies, even
if they endure over time, may increase die health
gap between the better and less well off (Winkleby,
1994), rather than narrowing it. This is especially
disconcerting because those who are of lower
socioeconomic status are at higher risk of disease
even prior to a campaign (Feinstein, 1993; Blane,
1995). Health promotion interventions which are
done with sincere intentions of doing good might,
in fact, exacerbate inequities in society. Despite
systematic, longitudinal and intensive health campaigns targeted at communities, researchers have
concluded that while gains in knowledge and
reduction in risk factors have indeed occurred
in the population as a whole, nevertheless, 'the
disparity in risk factors and mortality between
the upper and lower socioeconomic status groups
increased' (Winkleby, 1994, p. 1371). This disparity was documented in three major cardiovascular
disease prevention demonstration projects conducted in California, Minnesota and New England
(Winkleby, 1994).
This paradoxical outcome, which confronts our
sense of fairness and justice, can be informed by
the phenomenon characterized by researchers as
the knowledge gap (Tichenor et al, 1970; Gaziano,
1983). Researchers have observed that public cam-
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paigns that aim to enhance the knowledge of the
population consistently 'result in unequal acquisition of information between those who are welloff and those not-so-well off (Viswanath et aL,
1991, p. 712). The knowledge gap phenomenon,
is articulated by Tichenor et aL (1970): 'as the
infusion of mass media information into a social
system increases, segments of the population with
higher socioeconomic status tend to acquire the
information at a faster rate than the lower status
segments, so that the gap between these segments
tends to increase rather than decrease' (pp. 159—
160). This has been documented regarding knowledge about the prevention of heart disease in
communities that were a subject of health campaigns (Viswanath et aL, 1991). Researchers from
the Stanford Five City Project, a community-wide
cardiovascular disease prevention intervention,
noted that higher SES groups 'were motivated and
had the skills necessary to comprehend and utilize
the information presented in the campaign'
(Schooler et aL, 1991, p. 24). Recent studies also
point out gaps in the types of knowledge and
beliefs people have regarding ADDS transmission.
These gaps tend to be associated with education
and race, and have continued to exist from the
outset of the epidemic to more recent surveys,
despite mass-mediated and other health interventions (Adams and Hardy, 1991; AruftoetaL, 1991;
Hardy, 1991; McCaig et aL, 1991; Price and Hsu,
1992; Rogers et aL, 1993; Salmon et aL, 1996).
Individual level explanations for the source
of gaps, drawing, for example, on theories of
motivation and personal salience, abound in
research on the knowledge gap (Yows et aL, 1991)
and can serve as a rationale for targeting messages
to particular audiences. Structural factors, such as
differential access to resources, socioeconomic
opportunities and capacities to acquire and utilize
information (Gaziano, 1983), might provide even
more compelling explanations. Similarly, gaps in
health may be the result of a lack of real and
perceived opportunities to adopt health promoting
practices, rather than solely due to discrepancies
in motivation, knowledge and beliefs. For example,
those with lower income are more likely to be
iv
dependent on grocery stores that charge high prices
for fruit and vegetables, and have less variety
and lower quality foods (Onishi, 1995). Structural
factors are consistent with approaches that emphasize institutional, social and policy changes;
individual-level explanations are consistent with
educational interventions and social marketing
approaches. Viswanath et aL (1991), following
Tichenor et aL's (1970) analysis, conclude that
knowledge gaps are not apparent when the topic
seems relevant to all social classes, and that gaps
are less likely to occur if the intervention topic is
defined as an issue of community, rather than an
individual concern. They suggest that gaps are
also related to the structure of communities or
organizations to which people belong and conclude
that for the purpose of achieving desired health
goals there is a need to work on structural factors,
including the use of regulative actions. Clearly,
systematic gaps in knowledge are not inevitable
(Ettema and Kline, 1977; Ettema et aL, 1983;
Warner, 1987), and therefore we need to scrutinize
the assumptions that underlie the paradoxical outcome in gaps in knowledge and beliefs, and the
corresponding outcomes of health-risk gaps found
in the aftermath of prevention interventions.
The paradox of prevention
As described by Rose (1981, 1985), the Paradox
of Prevention occurs when 'a large number of
people at a small risk may give rise to more cases
of disease than the small number at a high risk'
(Rose, 1985). For example, using some of the data
provided by Rose (1985) on Down's syndrome
(Table I), it is clear that the risk of Down's
syndrome is almost 50 times higher in women
Table L
Maternal
age
Risk of Down's
syndrome
(per 1000)
Percent of
all births
Percent of Down's
syndrome births
<30
35-39
45 +
Allages
0.7
3.7
34.6
1.5
78
5
0.05
51
16
2
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over 45 years of age compared with women under
30 years of age. Despite the dramatically greater
risk in older women, over 50% of all Down's
syndrome children occur in women in the under
30 age group.
The explanation for the Paradox of Prevention
is relatively simple. While women under 30 have
the lowest risk of Down's syndrome births, they
account for over half of all Down's syndrome
children because 78% of all births are in the
younger age group. Similar patterns may be
observed with the impact of cholesterol and hypertension on heart disease, the effect of unprotected
sexual intercourse on AIDS, and many other risk
factors. This suggests that intervention strategies
that produce small changes in population-wide risk
factors (e.g. in blood cholesterol or systolic blood
pressure) may result in greater reductions in disease
levels than larger changes in high risk populations.
Thus, major reductions in disease levels in the
population may require that we focus our prevention efforts not just on high risk populations, but
may require population-wide approaches. Such
population-wide intervention may bring significant
benefits to populations, but offer little to participating individuals, at least in the short run (Rose,
1985).
This paradox raises important ethical and social
implications. If we use strategies focused on producing small, population-wide changes in risk factors,
such as blood cholesterol or systolic blood pressure,
we are asking the majority of individuals—many
of whom will not develop the specific disease
in question—to change their behavior. Moreover,
some behavioral recommendations, such as
increasing exercise levels, are not without risk. As
a result, many of those being asked to change will
not benefit from their efforts, and may increase
their risk from other causes (e.g. injuries). What
is the rationale for asking individuals to make
behavioral changes from which they may not
benefit? Do we have the obligation to adequately
inform the population that they may not benefit
from recommended changes? Do we have the
obligation to inform populations of the risk of
recommended behavioral changes?
The Tragedy of the Commons
The Tragedy of the Commons refers to calamities
that occur as a result of individuals pursuing solely
private ends or private goods. The classic example
of the tragedy is drawn from the history of grazing
lands held in common by members of rural villages
in medieval England (Hardin, 1968). The common
grazing lands were used to feed cattle, sheep and
goats owned by individual families in the village.
If each family only grazed one animal, the commons were able to be renewed each year. As
rational individuals, however, it was in the interest
of families to raise as many livestock as they could
produce. While the commons may have been able
to support extra use by a few families, if everyone
in the village acted in their short-term, individual
interest the number of animals quickly would have
exceeded the ability of the commons to renew
itself, and the commons would have been overgrazed, eroded and destroyed. The long-term consequences of 'commons' problems are negative
for individuals, families and the village.
As a metaphor for the consequences of individuals acting only in their own, short-term interests, the Tragedy of the Commons has been used
as a rationale for regulatory restrictions of environmental pollution. Specifically, in a completely
open economic market it is to the advantage of
companies to produce a product as cheaply as
possible. In such markets, the voluntary purchase
and installation of pollution control equipment to
protect air and water supplies may place a company
at a competitive disadvantage. Thus, companies
may ignore environmental protection unless
required to do otherwise, with the consequences
of destroying common goods, e.g. clean air and
clean water. Even if groups of companies were to
voluntarily agree on the importance of environmental protections, individual companies could
pursue competitive advantages by ignoring environmental issues. This is a variant of the free rider
effect, where some companies get a free ride as a
result of the action of others. In a sense, regulations
requiring companies to maintain environmental
quality may be thought of as restoring a level
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playing field while maintaining environmental protections.
The Tragedy of the Commons may be used
not only as a rationale for clean air and water
regulations, but for other public health interventions as well. For example, vaccinations against
the major communicable diseases are not without
risk. If a substantial proportion of the population
is already vaccinated, it may be in an unprotected
individual's interest not to be vaccinated, since the
risk of exposure to disease would be low. In order
to assure that a substantial proportion of the
population is vaccinated we have regulations
requiring that children be vaccinated prior to
enrollment in public schols. These regulations
serve to increase vaccination rates and reduce the
risk of 'free riders'.
While the application of the Tragedy of the
Commons is clear with regards to some healthrelated risks, such as vaccinations and threats to
the water and air supply, it is less clear to what
extent it applies to chronic disease risk factors. As
noted in the Paradox of Prevention, major gains
in reducing the societal burden from chronic disease will only occur through broad population
changes in risk factors, not through reductions only
in the high risk populations. This would suggest
the need for policy strategies. However, since
specific individuals may not benefit directly from
behavioral changes—including exercise, diet and
participation in screening programs—can we justify these strategies when populations, but not
many of the individuals in the population, benefit?
The problem, of course, with the policy
approaches suggested by the Tragedy of the Commons is the conflict with individual autonomy.
That is, the usual interpretation of the Tragedy of
the Commons is that it requires a policy approach
for resolution, and thus presents a clear antinomy
in which there are conflicts between the public
good and individual freedom. However, there are
alternatives to the policy strategies suggested by
the Tragedy, such as encouraging individuals to
pay attention to the longer term consequences of
their actions, and the importance of individual
behaviors to the well-being of the community. For
vi
example, Thompson and Stoutemyer (1991) used
a number of strategies to provide a sample of
California families with information on the importance and long-term consequences of water conservation, and the effectiveness of individual actions.
They found a significant effect of their interventions on water consumption. Thus, the Tragedy of
the Commons may provide support for voluntary
approaches, rather than relying solely on public
policy.
However, voluntary solutions are generally vulnerable to the problem of 'free riders', unless the
public is made aware of the free rider problem and
social pressures are brought to bear. For example,
it has been argued that the English commons were
not destroyed by individual members of the villages
pursuing their own welfare—since there were
strong social pressures to restrict the number of
livestock grazed by each family. Rather, the commons were destroyed by large landowners taking
over the common lands to increase wool production
at the start of the industrial revolution. Irrespective
of whether one uses voluntary or more coercive
policy strategies to address problems associated
with 'commons', it is clear that in both approaches,
resolution of commons dilemmas requires that
individuals recognize the importance of the community and collective interests.
The paradox of increased demands
The more health interventions make people
conscious of the connection between 'good
health behavior' and the importance of prevention, the more people's demands of the health
care system might increase, rather than
decrease.
The more people are encouraged to become aware
of health risk and to protect their health (e.g. by
exercising, consuming nutritious foods, participating in early detection activities), the greater their
expectations for good health. Consequently, the
more they are concerned about detecting and treating potentially adverse medical conditions, the
more the demand for expensive preventive, detection and treatment procedures will increase. This
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situation is not likely to decrease rising health
care costs (Callahan, 1990; Gaylin, 1993), since
preventive health measures and early detection of
disease or risk factors are not necessarily, from
an economic perspective, cost-reducing (Russell,
1986). The assumption that health promotion is
cost-saving might be misleading.
Another potential outcome, as discussed in die
Paradox of die Health Gap is that as health promotion interventions continue to raise the expectations
and demands of those who have more access to
resources from die health care system, they will
demand and receive more. Those, however, who
have less, will also expect less, and receive less,
thus increasing the health gap and social inequities.
The heavy promotion of health messages, regardless of peoples' ability to pursue services, can
have unintended consequences. It can result in a
population that puts a high premium on physical
well-being and is determined to master its fate,
but feels inadequate at doing so since (as discussed
in the information dissemination paradox) there
always seem to be new threats to be aware of or
newer ways to address old ones. This has led
Barsky (1988), a physician concerned with his
patients' growing obessions with health whom he
refers to as die 'worried well', to conclude:
The point is diat the pursuit of health can
be paradoxical. Secure well-being and selfconfident vitality grows out of an acceptance
of our frailties, our limits, and our mortality as
much as diey can result from our trying to cure
every affliction, to evade every disease and to
relieve every sympton. (p. xi-xii)
By trying to persuade people that they should feel
vulnerable and worry about dieir health, we also
are likely to raise dieir anxieties and sense of
dependence. Thus, die people whom we successfully persuade to feel vulnerable to illness unless
they adopt the appropriate preventive measures,
might also extend this feeling of vulnerability and
worry about additional risk factors diey need to
control in order to prevent potential harm. Thus,
aldiough they may be feeling healdiy, diey are
'worried sick' about being well. This corresponds
to a paradox attributed to Montaigne: a man who
fears suffering is already suffering from what he
fears (Hughes and Brecht, 1975).
How can we convince people to participate in
early detection activities but prevent over taxing
the health care system? How can we enhance die
early detection of disease, but help people realize
that not all possible health risks can, or should be
screened for? How can we avoid getting people to
'suffer from what diey fear' but still convince
diem to adopt behaviors diey resist or to refrain
from practices they enjoy? Is one strategy the use
of laws and regulations diat attempt to change
die environmental context of individuals and die
behavior of die public as a whole, dius minimizing
individuals' sense of vulnerability? Yet, if we do
not get people to believe dieir potential susceptibility to harm, will they be willing to accept policies
diat regulate their environment and dieir behavior?
Screening diose who are relatively privileged
for an increasing number of potential risks may
require expensive procedures (e.g. genetic tests)
that can tax die resources of die health care system.
This leads to another question related to die healtii
gap paradox: who will support policies diat aim to
promote people's healdi? Do people's life circumstances influence their support of protective social
policies? Will individuals with secure employment,
living in safer areas of die city, areas witii fewer
environmental hazards, be more or less likely to
demand more work and safety-related regulations
or pollution control measures dian diose who are
more vulnerable? Do diose who are dependent on
jobs diat may be jeopardized if diey are regulated
for safety or who are dependent upon local industries mat are sensitive to die costs of pollution
control measures support protection regulations as
strongly as diose who are less vulnerable?
Discussion
Apart from recognizing diat unanticipated consequences may occur in health promotion interventions—including the tendency to confuse people
widi excessive information, die reinforcement of
die healdi disadvantages of poorer elements in our
vii
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society, and tensions that may occur between basic
values—what can we leam from our examination
of these paradoxes? First, it is important to note
that for some people paradoxes beg neat solutions
(Harmon, 1995). It would be much easier if health
promotion was a neat and logical puzzle with a
single rational answer. The solution to our puzzles
would provide us with both an absolute moral
justification for our interventions as well as perfect
strategies for accomplishing our goals. The paradoxes we presented, whether they are 'true' or
'false', challenge the assumption that health promotion problems are simple puzzles that can be
easily solved.
Second, while some paradoxes may not be
resolvable, they may be amenable to partial solutions through refraining the issues (Rappaport,
1981). Rose's prevention paradox, for example,
points out that the precise benefits that will accrue
to a given individual from a preventive measure
are uncertain. In spite of this uncertainty, many of
the theories used in health education focus on the
risks to an individual. The apparent contradiction
between the prevention paradox and our theories
of behavior change presents us with a conundrum.
Is it appropriate to persuade people that they
personally are at risk of developing a disease and
that they personally will benefit from changing
their behavior when we cannot make any guarantees? How much do we need, to know about risk
and how high must a risk be before intervention
becomes ethical?
One way to reframe the issue is to appeal to a
communitarian ethic rather than to individualism.
We know that small changes in large groups of
people benefit public health. Beauchamp (1988)
argues that:
Strengthening the public health includes not
only the practical task of improving aggregate
welfare, it also involves the task of reacquainting
the American public with its republican and
communitarian heritage, and encouraging citizens to share in reasonable and practical group
schemes to promote a wider welfare, of which
their own welfare is only a part In political
viii
individualism, seat belt legislation, or signs on
the beach restricting swimming when a lifeguard
is not present restrict the individual's liberty for
his or her own good. In this circumstance the
appropriate slogan is. "The life you save may
be your own'. But in the second language of
public health these restrictions define a common
practice which shapes our life together, for the
general or the common good. In the language
of public health, the motto for such paternalistic
legislation might be: "The lives we save together
might include your own', (p. 35)
A third insight gained through our examination
of these paradoxes is recognition of the need to
identify divergent solutions, realizing that whatever
strategy we adopt will lead to additional tensions
and issues that will need to be addressed
(Rappaport, 1981). For example, the field is evolving to incorporate public policy initiatives that
modify the social and physical environment
(Luepker et aL, 1994; Winkleby, 1994; COMMIT
Research Group, 1995; Fisher, 1995). The tensions
that will be raised by the increased emphasis on
public policy include conflicts between autonomy
and the social good. For example, if we are able
to successfully promote policy-level interventions
will we infringe on the rights of individuals?
Currently proposed public health measures such
as the restriction of tobacco advertising (Brownson
et aL, 1995; Rogers et aL, 1995), the enactment
of zoning and tax policies to promote physical
activity (King et aL, 1995), and regulations for
institutional food service operations (Glanz et aL,
1995), emphasize the public good over individual
freedom. To date, the tobacco control movement
has been the most successful in securing environmental and policy level change. As we attempt to
facilitate similar changes in other arenas such as
diet and physical activity, we may encounter more
accusations of public health paternalism and violation of individual rights.
Perhaps because of our society's concerns with
autonomy and individual freedom, most of our
policy interventions have been consistent with John
Stuart Mill's (1963) harm principle:
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The only purpose for which power can be
rightfully exercised over any member of a
civilized community, against his will, is to
prevent harm to others. His own good, either
physical or moral, is not sufficient warrant. He
cannot rightfully be compelled to do or forbear
because it will be better for him to do so,
because it will make him happier, because, in
the opinions of others to do so would be wise
or even right. These are good reasons for
remonstrating with him, or entreating him, but
not for compelling him, or visiting him with
any evil, in case he do otherwise. To justify
that, the conduct from which it is desired to
deter him must be calculated to produce evil to
some one else. The only part of the conduct of
any one, for which he is amenable to society,
is that which concerns others. In the part which
merely concerns himself, his independence is,
of right, absolute. Over himself, over his own
body and mind, the individual is sovereign,
(pp. 949-1041)
While our policy approaches to date have generally
been consistent with the harm principle and balanced with concern for a person's rights for autonomy, the increased emphasis on developing new
social policies needs to be viewed with caution. Not
only do policy-level interventions raise tensions
between important values, they can represent fundamentally different approaches. Different types of
policies illustrate the perplexing tensions between
needs, rights and obligations of individuals and
society as a whole. The first type of policies serve
as corrective measures for social inequities by
mandating services, subsidies or facilities for those
with limited access or resources, e.g. mandating
coverage of mammography under Medicaid. This
type of policy can help eliminate barriers, while
helping to create an environment that facilitates
adoption of health-promoting behaviors (Brown,
1991). A second type of policy offers incentives
to organizations and/or individuals to engage in
certain activities or to produce health promotion
products or services (e.g. tax deductions for worksite health promotion programs). These policies can
also be seen as corrective of a marketplace that
does not necessarily provide free choices to all
(Beauchamp, 1987; Bellah et al, 1991). A third
type of policy penalizes individuals or organizations that engage in disease-promoting enterprises;
e.g. increasing the Federal excise tax on tobacco
products. This strategy makes it more difficult or
less desirable to engage in the health-damaging
behavior (Brown, 1991). The first and second types
of policies enhance opportunities while leaving the
individual with the freedom to choose. The third
type, while sanctioning those who indulge, leaves
the option of engaging in the behavior, albeit at a
higher cost, to the individual.
Some policies are compromises. Addictive substances such as tobacco are officially restricted to
a certain segment of the population, children.
Others are permitted to consume them, but are
warned about the harm they cause to their health.
Thus, restrictions apply only to those considered
unable to make mature choices. Clearly, this contradicts the ethic of protecting the public from harm,
since we continue to allow the promotion of
harmful substances such as tobacco, alcohol and
guns. This is compounded by evidence that vulnerable populations are specifically targeted by such
promotion efforts (Flewelling et al, 1992).
Restrictive policies, whose proponents say have
proven to be quite effective (Grossman et al,
1987; Flewelling et al., 1992; Holder, 1993; Grube
and Wallack, 1994), limit the access of children
who presumably cannot make free choices on their
own, but leave the free choice of whether to
consume them to the mature consumers. These
presumably free choices are contested by critics
who maintain that they are clouded by manipulative
marketing strategies or life circumstances. Finally,
there are policies that instead of providing restrictions, actually impose certain behaviors: whether
to wear helmets, seatbelts or get immunized. One
has to perform a certain act to adhere to these
policies.
With the growing emphasis on policy-level solutions, the following questions can be asked: Which
policies work best? Which policies are consistent
with our social values and which contradict them?
IX
Editorial
Which policies are more likely to be accepted by
the public? Which policies might backfire and
produce resistance, simple neglect or preemptive
policies? Implicit in these questions and the
answers to them are our assumptions about the
process of advocacy and the role of health educators
in the policy process. If we assume that policies
should be a result of a democratic process and
reflect the collective choice of the public, then
policies need to be formulated in the context of
an informed discourse about the issues. Advocacy
then becomes a process of making a compelling
case for the use of a regulative strategy to grassroots
members of the public as well as to public officials.
Policies adopted as a result of this process can
be compared to what ethicists call second-order
choices—choices in which people choose to let
others make a choice for them (Childress, 1990)
or to have their own actions restricted for their
own or the good of the public.
Obtaining public support for policies has been
shown to be important for the development and
implementation of effective substance control policies (Page and Shapiro, 1983). Studies show
that policies that support restrictions on access to
disease-promoting substances (e.g. banning cigarette vending machines, minimum drinking age,
zoning liquor sales establishments), raise mixed
feelings and emotional responses among the public
and decision makers. They remind people of prohibition and raise concerns regarding infringement
of individual's autonomy, intrusion on privacy, and
protection of the First Axnendment and commercial
free speech (Beauchamp, 1988; Gostin and Brandt,
1993; Casswell, 1994). Despite such concerns,
the majority of people support such restrictions,
especially if they perceive that these policies will
protect populations such as children and adolescents, who are seen as particularly vulnerable and
unfairly targeted by marketing and promotional
efforts of manufacturers (Jeffery et al., 1990;
Taylor, 1990; Slade, 1992; Gallup, 1993). Despite
this support, people might not be aware of the
strong support they and policy-makers have for
policy solutions. As a result, policy makers are
often timid in their legislative initiatives, and
enforcement of and compliance with existing
restrictions tend to be relatively limited (DiFranza
and Brown, 1992; Forster et al., 1992; O'Leary
et al, 1994; Bartechi et al, 1995).
In closing, paradoxes can serve the function of
making explicit that intervention strategies should
be divergent. They also point out the dialectical
nature of the problems we try to address. For
example, our promotion of policies that regulate
peoples' behaviors in an effort to protect them, at
the same time, might infringe on certain rights. As
Rappaport (1981) states:
If it is correct that solutions create problems,
which require new solutions, this should be of
some interest to us, but not because we can
expect to find a solution once and for all. Rather,
it is the paradox itself that should be of interest
because that should tell us something about the
fact that a variety of contradictory solutions
will necessarily emerge and that we ought not
only expect but welcome this, because the more
different solutions to the same problem the
better, not the worse, (p. 9)
As we attempt to improve the public's health
through increased environmental and policy interventions, contradictions and tensions identified
in the paradoxes discussed in this editorial and
elsewhere will become more salient As a field,
we need to ask ourselves if, in light of our strong
move toward policy solutions, our code of ethics
(Taub et al, 1987) and principles of practice reflect
a recognition and appreciation of multiple and
possibly conflicting values and divergent and multilevel solutions.
Nurit Guttman
UMDNJ
Robert Wood Johnson Medical School
Department of Family Medicine
One Robert Wood Johnson Place, CN19
New Brunswick
NJ 08903-0019, USA
Michelle Kegler
Department of Health Promotion Sciences
College of Public Health
Editorial
University of Oklahoma
PO Box 26901
Oklahoma City, OK 73190, USA
Kenneth R. McLeroy
Department of Health Promotion Sciences
College of Public Health
University of Oklahoma
PO Box 26901
Oklahoma City, OK 73190, USA
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