The Greater Good

No...it's food...that's all

Most people of libertarian instincts have a degree of difficulty with large scale public health initiatives, control and rights over one's own body being surely the first and foremost battlegrounds from where the forces of an overbearing state should driven back at every opportunity.

Despite this principle all but a few people on the loopy fringe do accept the immense and undeniable good that can flow from some innovations, especially in the field of vaccination; I seem to remember an especially stirring defence of the concept, now a reality, of vaccinating teenage girls against the horrific downstream consequences of Human Papillomavirus from, if I remember rightly, that bastion of the authoritarian left, Devil's Kitchen. I think most libertarians would be rightly against absolute compulsion, but even government's tend not to seek this and in allowing vaccination to occur by default, usually at school, thereby nullifying the impact of those parents who would otherwise be too disinterested in their child's welfare, a fairly comfortable armistice can be declared.

It is not though an unconditional ceasefire. Where the risks and rewards of such initiatives are more evenly balanced the choice must remain actively in the hands' of the individual. The arguments over fluoridation of the water supply were before my time, though I understand they were quite heated for a time. I suspect that given how limited the evidence still seems to be of a potential down side, decades on, I doubt that it would be high up my list of grievances against the apparatus of the state.

The same latitude though cannot be applied to government plans, thankfully being reviewed, to add folic acid to all flour or bread even if the aim, to reduce birth defects such as spina bifida, is laudable.

The situations are not equivalent as ministers were claiming some months ago. The earlier case was one where a benefit to the vast majority of the community needed to be balanced against a rather nebulous suggestion of risk; the current proposal places a benefit to a small and relatively easily identifiable segment of the populace against risks with significant scientific support to a much larger group of people who in many cases may not even be aware that they are in the 'at risk' club.

It is true that folic acid is at its most effective in the early stages of pregnancy, but the data as quoted by the government seems not to suggest that it is not that there are legions of women unaware of their pregnancy for several months, but that despite the health advice, too many fail to take the recommended supplements.

The government instinct is, of course, that 'something must be done', and perhaps in this case it should. Look at why the information campaigns have failed. A discussion on Radio 4 this week revealed that we buy more books on pregnancy, childbirth and child rearing every year than there are live births. Most statistics on women availing themselves of neonatal services are, I'm assured by a doctor friend, very good; this will come as no surprise to anyone who has been shown more unintelligible prints of ultrasound scans than you can shake a stick by excited friends. It isn't beyond the wit of either man or woman to persuade pregnant women to take a pill each day; for god's sake a significant proportion will have only just stopped taking a pill a day to become pregnant. Don't accuse me of misogyny - it's the alternative attitude that would reflect worse on women.

If you want to ship a nine months' worth of folic acid supplement, free of charge, to every mother-to-be in the land at tax payers' expense, go right ahead - the economics of it are pretty good as it happens. Let's target effective therapies on those who need it, not subject the remainder of us to a therapy that may not be just worthless but potentially very dangerous.

I'm far from a Luddite and generally am very positive about what medical science can do for us, but this proposal looks like a pretty big throw of the dice. I don't criticise the fact this idea has been considered, but by any standards the evidence is pretty equivocal, and lies far from the levels of confidence that a measure like this should be underpinned by.