by Dr Ishma Harford
The premise of society is that people be organised in a way that produces the most good for the most people. However, individual freedoms often come into direct conflict with this premise.
Health systems must navigate this tension, as many of the most impactful initiatives must toe this line. Certain activities, vaccination being the most recognisable, benefit people they never directly targeted. A vaccine given to one child protects the infant too young to be vaccinated, the grandmother whose immunity has faded, and the classmate whose parents do not believe in vaccines. The good spills over and benefits others beyond the person who received it.
The same spillover works in reverse. Some actions, small in scale and private in intention, also affect others in unexpected but important ways. Smoking in public is a prime example. The World Health Organisation estimates that second-hand smoke kills more than 1.6 million people every year, and states plainly that there is no safe level of exposure. It causes heart disease, respiratory disease and lung cancer in people who never lit a cigarette.
Vaccines and second-hand smoke are two sides of the same coin. Economists call these externalities. Where an individual makes a decision in their own self-interest, but it indirectly affects others, externalities enter the conversation.
When you decide to vaccinate your child, you may not be thinking about your neighbour, but the herd immunity benefits them too. In the same way, smokers may not consider the harm their smoke does to others, but it is inarguable that second-hand smoke kills.
Because we may not always consider how our actions affect our neighbours, it is the duty of collective society to protect the public goods we share. Herd immunity and clean air are two such goods, beneficial to us all, even to those who did not contribute to them.
Protecting public goods is how we protect our most vulnerable and make healthy living equitable. It is how we look out not only for our neighbour, but for Grenada, and how self-interested decisions become lifesaving missions.
Yet, they are fragile. In the same way that the actions of the majority can benefit the minority, sometimes it only takes a few to rob us of the goods we all enjoy. Measles provides an excellent example. Protection against it is generally achieved when about 95% of people are vaccinated, shielding the few who are not. One study in the United States found that if childhood vaccination coverage fell by just 5%, measles cases would triple. The choices of a small minority can be detrimental to us all.
This is where vision becomes critical. It is very easy for the individual to become preoccupied with the things life demands, and lose sight of the bigger picture. We unknowingly trust in the systems society builds to protect the public goods we often take for granted.
That we rarely think about these goods at all is a success in itself. It represents a collective peace of mind. But that peace comes at a price. Children must still be vaccinated, the air must still be kept clean, and the efforts that sustain these goods must continue long after we have stopped noticing them.
The old adage holds: you never miss the water till the well runs dry.
Dr Ishma Harford is a medical doctor and a Commonwealth Scholar completing a master’s degree in Health Analysis, Policy and Management. The Health Imperative is an educational, politically neutral column about health, the system that delivers it, and all the implications in between.
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