It all starts with tax cuts. No, really, it does.
In the 1980s, Ronald Reagan and Margaret Thatcher unleashed the age of neoliberalism, which revolutionized the way we think about the role of government. Essentially, the question they posed was this: instead of taxing citizens to enable the government to provide them with the services they need, why not reduce their taxes and allow them to pay for services themselves? The idea eventually spread to Canada, with all three governments slashing, to varying degrees, personal and corporate tax rates to almost unanimous applause. After all, who doesn’t like a tax cut?
The problem is, the ideology of tax cuts doesn’t account for contingencies like wars, natural disasters, and large-scale demographic shifts, the kinds of things that require a coordinated response from entities larger than the individual. This can lead to problems. For example, the current American president’s refusal to roll back tax cuts while his country fights no less than two wars has led directly to the highest deficit in U.S. history. Similarly, Hurricane Katrina exposed the decades-long neglect of federal emergency management agencies, which could barely manage to stage a decent photo-op as hundreds of American citizens drowned.
But what does this have to do with smoking, Vila?
For years, experts have warned that when the swollen ranks of baby boomers reached retirement age, they would create an unprecedented burden on the health care system. In the United States, which does not have universal health care, the strain is being felt by private and government-sponsored insurance programs, which are doing everything they can to reduce costs. In Canada, the pressure is borne by the public health care system, which, having been starved for funds for more than a decade, is now in noticeable decline. As the demand for health services increases, the ability of the system to deal with the influx of aging Canadians is being stretched to the breaking point. Without question, something needs to be done.
Pre-Reagan, the logical solution would have been to raise taxes to pay for the rising cost of health care, just as pre-Bush, taxes were understood to be one of the sacrifices a nation must make when it goes to war. Today, by contrast, the ideology of tax cuts is so deeply entrenched that no politician in their right mind would risk suggesting even a small increase. Therefore, they are forced to look elsewhere for alternatives.
In the case of health care, the solution that presented itself was to once again shift the fiscal burden from government to the individual, by way of the doctrine of prevention. From this perspective, it isn’t the government’s responsibility to look after the health of its citizens—it’s the individual citizen’s responsibility to look after themselves. In other words, since government can no longer afford to take care of us when we’re sick, the onus is on us not to get sick in the first place. And if we do, it must be our own damn fault.
Of course, prevention isn’t in and of itself a bad idea, up to a point. That point being reached when the imperative to prevent disease brings with it the social denormalization of those considered to be unhealthy. Smokers, of course, have been the primary target of denormalization campaigns for more than twenty years. However, as this article clearly shows, the next targets are the overweight and the obese, whose afflictions, like that of smokers, are thought best treated “like a communicable disease.”
Economics aside, there is something suspiciously moralistic about the doctrine of prevention, as well as something deeply intolerant about the way it is applied to human beings. It assumes, as statisticians often do, that an ideal individual exists, one who embodies a norm of perfect healthfulness from which the rest of us deviate. As (Dr.) David Romano recently reminded me, government studies that purport to show the increased health costs of smoking do so by assuming that a non-smoker uses $0 of health care—i.e., that non-smokers never have cause to visit a doctor, to stay in hospital, or, presumably, to ever die.
This is preposterous. Yes, smokers have an increased risk of cardiovascular disease and some cancers. But smoking is one of several thousand possible causes of illness, quite a few of which can be linked to behavioural choices. For example, the second most common form of cancer among women (after breast cancer) is cervical cancer, which in the majority of cases is caused by infection with the Human Papilloma Virus, a sexually transmitted disease. Should we infer, then, that sex is the second greatest health threat to women, and therefore to be avoided at all costs? I certainly hope not.
Behaviour aside, a certain propensity for unhealthfulness is, unfortunately, part of the biological fact of being alive. My brother has never smoked a day in his life, but his health, which is otherwise excellent, has been profoundly compromised by an inherited gene that causes schizophrenia. There is nothing he could have done to prevent his condition (except, perhaps, to take up smoking), and his long-term prognosis is poor at best. In fact, studies indicate that, even as a habitual smoker, I will probably outlive him. Is this fair? No. But it’s the way life is.
In any event, the health care system is no better equipped to take care of my brother than it is to take care of me, and this fact exposes the lie that is at the heart of the doctrine of prevention. If I have to wait three months to see a doctor, or cannot get the surgery I need, then some of you will say that I deserve what I get because I choose to smoke. But what will you say to my brother when the voices in his head drive him to seek medical help, but when, because of reductions in health spending that are the consequence of tax cuts, there is no bed for him at the hospital, no outpatient care to give him, and no social worker to make sure he doesn’t fall through the cracks of our broken system? Does he somehow deserve it too? More to the point, do you?