As everyone knows, there has been another historical reversal: obesity was once the problem of the rich, but now, epidemiologically speaking, it is a problem of the poor. Curiously enough, in the light of a general denial of personal responsibility for conduct, there have of late been increasing attempts by doctors and public health authorities to pay, or to bribe, the poor into behaving healthily, for example by giving up smoking. There have even been experiments to get drug addicts to give up by means of payment, either in cash or in kind. A certain success has been claimed for these methods; and thus, as the British Medical Journal put it in the same week as the NEJM editorial, “Using cash incentives to encourage healthy behaviour among poor communities is being hailed as a new silver bullet in global health.”
But cash payments can work only if people are capable of making choices. How then do we resolve the contradiction? I hesitate to quote a doctor of philosophy rather than of medicine, but here is what Karl Marx had to say:
Men make their own history, but not just as they please; they do not make it under circumstances chosen by themselves, but under circumstances directly encountered, given and transmitted from the past.
Only public health doctors and experts in communication are free of such constraints, and they make history for other people.
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