Big Brother Prescribes

Are mandatory aerobics classes in your future?

"When anyone dies at an early age from a preventable cause in New York City, it's my fault," New York City Health Commissioner Thomas Frieden declared recently (Financial Times registration required). In his campaign to make sure that no New Yorker dies before his or her time, Frieden has adopted an expansive notion of public health.

Historically, public health has focused on protecting people from the risks of communicable diseases. Thus public health officials have been empowered to mandate vaccinations, require the chlorination of water, order that milk be pasteurized, and quarantine sick people in order to control epidemics. Even the city's recent broad smoking ban was justified in part on the grounds that smokers were harming the health of others by exposing them to second-hand smoke.

But safeguarding people from the risks potentially imposed on them by third parties is no longer enough—Frieden now wants to protect people from themselves. So New York's Board of Public Health has turned its attention to the city's diabetics. In January 2006, the city's health bureaucrats began implementing a surveillance program that will eventually include nearly all of the city's 530,000 diabetics. In the current issue of Science, Columbia University professor of sociomedical studies Amy Fairchild, writes, "If New York comes to serve as a model, public health surveillance will take on a radical new form, entailing a reconfiguration of the relation between public health and medicine."

New York's radical new surveillance system requires mandatory electronic reporting of the glycosylated hemoglobin A1c values of all diabetics tested by all city laboratories to the Department of Health and Mental Hygiene (DOH). Keep in mind that diabetes is not a communicable disease. The recent increase in diabetes among Americans is associated with the increase in obesity. Unlike measles, a person cannot catch it merely by standing next to someone munching on a Krispy Kreme donut or pigging out on slices of Famous Ray's pizza.

Nevertheless, diabetes is a health problem for 20 million Americans. Diabetics have higher than normal levels of glucose in their blood. Years of higher blood glucose eventually damage small blood vessels leading to high blood pressure, and to kidney, heart, and nerve disease. One physician friend told me that he adds ten years to the age of his diabetic patients. Testing for A1c measures the average level of glucose in the blood for the past 2 to 3 months. Thus it's a convenient way for diabetics and their physicians to check how well they have been controlling their glucose levels. Generally A1c values for non-diabetics are below 7 percent and studies show that the closer a diabetic can keep this value to 7 percent or below, the less likely he or she is to suffer from the complications of the disease. Unhappily, one study estimated that only 37 percent of diabetics in the United States maintained A1c values below 7 percent.

Under the new city diabetic surveillance system, the results from all tests for A1c (estimated to be between 1 million and 2 million annually) will go the city's DOH. The registry will record the full name, date of birth, and address of each person tested and the date each test was performed. Diabetics whose A1c levels are too high will receive a letter and educational materials from the DOH and their physicians will be alerted to their test results. Frieden says that the surveillance information collected will remain confidential and any diabetics who don't want to hear from the DOH can opt out, but they cannot prevent their test results from being filed in the registry.

In her discussion of the diabetic surveillance program, Fairchild makes a distinction between "hard" and "soft" paternalism. "What distinguishes hard paternalism from its softer counterpart is the role of coercion," she writes. Fairchild concludes that the surveillance system is acceptable soft paternalism because "no one would be forced to undergo treatment or lifestyle change." What's wrong with a little education, courtesy of the DOH? As it stands, nothing much; but will the DOH's interventions stop at non-coercive letters, phone calls and pamphlets?

In the United States, the health care costs for diabetes top $45 billion annually and absorb 25 percent of Medicare's budget. In addition, 42 percent of diabetics receiving Medicaid in New York City have dangerously high A1c levels of above 9 percent. Should the chiding approach of letters and phone calls fail to get results, it's not difficult to imagine that Frieden and other city health officials would argue for applying a bit of "hard" paternalism because poor diabetics are busting city and state health care budgets. One step toward harder paternalism might be compulsory exercise and nutrition classes.

And why stop at monitoring diabetics? After all, far more Americans suffer from cardiovascular diseases than they do from diabetes. For example, 65 million Americans have hypertension (there is some overlap with diabetics); 100 million Americans have above-normal cholesterol and 35 million have high cholesterol. Heart disease costs nearly $200 billion in direct medical costs every year, much of it also picked up by Medicare and Medicaid. New York's diabetic surveillance program could be the harbinger for similar mandatory programs for monitoring everyone's serum cholesterol, hypertension, and even percentage of body fat.

In the past, Americans recognized a distinction between public and personal health. If I smoked, drank too much, supersized regularly or failed to get to the gym, it was my own fault, not Health Commissioner Frieden's. However, when (and if) government-funded universal health insurance becomes a reality, the distinction between public and personal health will fade away. Then get ready for your prescription for compulsory biweekly aerobics classes.