American anxiety over healthcare costs and obesity continues to fuel public health advocacy for increased taxes on sugar-sweetened beverages and other unhealthy foods. Proponents of imposing higher taxes on unhealthy food products, such as soda, claim they are a necessary and effective strategy for modifying consumption behaviors and improving health outcomes. The logic is that a tax will make unhealthy foods more expensive, thereby deterring people from consuming them in excess. Advocates argue that excessive consumption of sugar-sweetened beverages not only harms individual health, but also induces increased healthcare costs that cause societal harm. Since rising healthcare costs negatively affects the public, they propose that governments are justified using fiscal policies to intervene to nudge individuals to change their dietary choices. This logic has persuaded residents of Berkeley, Seattle, and Philadelphia to vote in favor of implementing a sugar-sweetened beverage excise tax. Despite fervent support from public health advocates many people remain skeptical of imposing excise taxes on sugar-sweetened beverages as a public health solution.
I have to admit, when I was first exposed to the concept of “nudging” and soda taxes, I found them appealing. However, after in depth reflection about my values as a public health scholar, my perspective has shifted.
In late 2017, Cook County repealed its sugar-sweetened beverage tax due to intense opposition after the tax failed to live up to expectations. A major concern of using taxes to shift dietary choices is their disproportionate impact on low-income households. Higher prices on consumer goods disproportionately affect households of lower socio-economic status than wealthier households. This concern for equity was explored in a recent Lancet article, which has been touted as “a new weapon in their battle against sugar” by a review published in Fortune. The authors of the Lancet article conclude that although price policies DO often bear the largest tax burden, governments can justify this burden if the estimated health benefits of decreased consumption are likely to disproportionately benefit poorer households. This moral trade-off assumes that sugar-sweetened beverage taxes are effective at improving diet patterns and health. However, this assumption is just that-an assumption- since the evidence in support of substantial behavior changes or health impacts is weak. Even so, when it comes to public health, debating the equity of excise taxes of unhealthy food products misses the forest for trees.
The Big Neoliberal Distraction
Taxing unhealthy food items to modify individual behavior is part of a neoliberal trajectory in public health discourse. Neoliberalism is the prevailing political-economy paradigm that emphasizes free-market consumerism, individual responsibility, and minimal government spending. A variant of neoliberalsim, referred to as libertarian paternalism, legitimizes the role of private and public institutions in using market-based strategies to influence private behavior so that an individual’s freedom of choice is maintained. Fiscal policies, such as excise taxes, are a market-based strategy that nudge individuals into taking responsibility for their health are a form of libertarian paternalism in public health.
The push for increasing taxes on food items deemed unhealthy is occurring in midst of a larger political-economic wave of tax cuts for wealthy households and corporations, increased corporate consolidation, decreased public investment in education, calls to cut investment in Medicaid and privatize Medicare, restrict SNAP eligibility, threats to environmental regulations, and persecution of labor rights–all policies that contribute to increased economic insecurity that leads to stress (weight gain) and decreased ability to purchase adequate healthy food. This neoliberal agenda erodes an institutional environment that provides the greatest support for health while painting soda-drinkers as social deviants. It is within this context that The Lancet article argues that even though increased price of soda disproportionately affects people of low socioeconomic status, soda taxes may be just because these same people may realize greater health benefits than people from higher socioeconomic statuses. But is the fact that low-income individuals might benefit more in terms of health from this policy enough to claim that the policy is just?
Neoliberal public health strategies that aim to “fix” a single behavior (drinking soda or eating junk food) are reductionist in nature and ignore the underlying socio-cultural determinants of behavior and health. This paradigm of public health views solutions to complex phenomenon like health in terms of singular components isolated from the larger socio-political context. It penalizes people for “what they do wrong and what they fail to do right” while conceptualizing health as an individual responsibility rather than a right or public good. Conceptualizing health as an individual responsibility that governments can encourage through taxation distracts the public health discourse from advocating for strategies such as investment universal healthcare, public education, and living wages. Unhealthy diet patterns and poor health outcomes are in part a symptom of deeper structural factors exacerbated by neoliberal policies and cannot be resolved simply by taxing “bad” food items.
When arguing in support of increased soda taxes, public health advocates often lament the power of “Big Sugar” or “Big Soda” and suggest that the increased cost to consumers, and theoretical decrease in purchases, will shift enough revenue away from large beverage corporations to curb their control over people’s dietary choices. Again, this deflects the public health discourse away from more effective strategies for curbing corporate power like enforcement of anti-trust laws or support for labor rights and casts the individual in the role of starving the beast. It also overlooks the role crop subsidy policies play in making sugar so cheap to begin with. Focusing attention on taxing soda instead of the root causes of extreme corporate power feeds into the neoliberal agenda of deregulation at the macro level that further increases concentration and power in the food industry. The exact opposite of what public health advocates claim they are fighting for.
Beyond Soda Taxes: Seeing the Public Health Forest
Wellness, and not the individualized form of it popularized by self-help health gurus, offers an alternative paradigm through which to think about public health policy. It is a holistic and affirming process that focuses on cultivating factors that support human health and well-being, rather than on just preventing factors that cause disease (i.e., drinking soda). Wellness is a function of, and must be understood in the context of, justice at the interpersonal, organizational, and community (national) level. This goes beyond merely debating the equity burden of a soda tax and forces us to look at soda taxes within a larger institutional environment that determines resource distribution among members of a society. Public health professionals should concern themselves with the wellness implications of sugar taxes in terms of justice and systems that support people to have healthy lifestyles rather than penalizing them for the choices they make within the context of systems or environments that are unsupportive of healthy lifestyles.
Procedural justice is concerned with how resources are distributed to members of society. It is possible that resources can be distributed to low-income households in paternalistic ways that do not affirm dignity. Penalizing low-income individuals for their soda consumption with additional taxes may raise revenues for public institutions to provide nutrition education or fruit and vegetable subsidies to “benefit” these households. But who has the power to determine what constitutes a benefit, or which benefits are valued more highly than others? This resource allocation decision is often made by powerful individuals or institutions to serve their own agendas rather than by the individuals most affected by poor health and/or soda taxes. Therefore, imposing soda taxes to nudge low-income soda-drinkers into changing their behavior and justifying it by “giving” them nutrition programs do not cultivate wellness in the big picture. To truly promote wellness, resources should be distributed to those most in need through procedures that are just. Soda taxes do not meet this criterion.
The current discourse on soda taxes as a desirable public health strategy shifts conceptualization of health away from being a public good that is supported by an institutional environment consistent with standards of distributive and procedural justice. Viewing health as an individual responsibility divorced from one’s social environment further marginalizes disadvantaged populations and reinforces current health inequities. Public health advocates should consider the following wellness-oriented guidelines when supporting public health policies: (1) look at the public health data differently: instead of looking at populations who have succumbed to a problem like diabetes to find out what they are doing wrong, look at those who are succeeding and try to find out why they are doing well; (2) persuade policy-makers to consider outcomes related to success (e.g., greater consumption of fruits and vegetables), not just outcomes related to problem reduction (e.g., decreased soda consumption); (3) elevate the importance of social justice and consider the harmful effects to health and wellbeing of reductionist policies that penalize or demonize people for health-related lifestyle choices; and finally (4) stimulate the development of innovative policies that cultivate the environmental and institutional conditions for these desired outcomes to occur. Public health advocates need to look beyond soda taxes and use their political capital to advocate for investment in systems like universal health care, public education, and living wages if they are truly concerned about health and equity.