Straw nanny

‘The government is at pains to avoid being accused of “nanny statism” – the current code for unwelcome interference in personal freedom. I have not heard a single speech by a health minister in recent months without this terrifying prospect being wheeled out.’

So wrote Anna Coote under the headline ‘Nanny madness’ in the UK Guardian on 26 May (1). But who is accusing the government of ‘nanny statism’? It may be possible to hear such criticisms from retired colonels in gentlemen’s clubs in London or read them in the letters pages of the Daily Mail or Telegraph, but they are, like the Conservative Party, of marginal public influence. The only significant pressure on health ministers is urging them to pursue more interventionist policies. This indeed is the point of the article by Anna Coote, health policy director of the King’s Fund thinktank, who asks ‘what’s so terrible about the nanny state, anyway?’

In its response to the government’s public health consultation paper Choosing Health?, the British Medical Association echoes Coote’s view, arguing that ‘in relation to certain areas, a greater danger than nannyism is abdication and a failure to act – the Pontius Pilate approach’ (2). Given the BMA’s apparent conversion to the gospel according to Mel Gibson, it may be worth recalling that the destruction of the Temple in Jerusalem a few years after Pilate’s controversial hand-washing incident suggests that the Roman state was not entirely averse to coercive interventions. The BMA’s contribution varies between the silly (‘the only difference between smoking and Russian roulette is the delayed effect’; ‘smoking is so dangerous, on a par with heroin or duelling’) and the incomprehensible (‘to some extent, “joined-up” policy that is cognisant is the holy grail of public health’). If an organisation as cautious and conservative as the BMA can dismiss the danger of the nanny state, this is a sure sign that the danger is non-existent.

The term ‘nanny state’ is a misnomer for the current form of authoritarian government. The concept of the ‘therapeutic state’ better captures the distinctive character of public health under New Labour. The target of government measures aimed at changing a wide range of behaviours deemed to be unhealthy is the individual citizen who has internalised a sense of personal inadequacy and responsibility for health. Though government intervention is more coercive and intrusive than in the past, it is mediated through a range of ‘caring’ professionals and its authoritarian character is obscured. Nanny is a straw person, the counsellor is the personification of the therapeutic state.

A nanny state is one that is authoritarian but paternalistic, bossy but benevolent. Nanny forces the children to eat their greens and to take their medicine, but it is only for their own good. In some respects, the British government during the Second World War behaved in this way, imposing food rationing, media censorship, restrictions on travel, blackouts, etc. Emergency measures to contain epidemics, from smallpox and cholera in the nineteenth century to SARS in the twenty-first, involve restrictions on civil liberties, such as quarantines, to limit the wider threat to society. Regulations to reduce death and injury on the roads – speed limits, breathalyser tests, seat belts, motor cycle helmets – are more familiar examples of ‘nanny state’ initiatives.

Nanny state measures tend to be imposed collectively and temporarily, justified by exceptional circumstances, such as war or pestilence. If, like driving regulations, they are introduced with long-term effect, this requires convincing evidence that they achieve the desired benefits (which was rapidly produced). It is worth noting that, even when these conditions have been fulfilled, there has often been considerable popular resistance to such measures. Though the nanny state has generally been able to rely on support from doctors and other professionals for its policies, it has also had to resort to coercive powers to enforce compliance with regulations introduced to enhance public welfare.

The most striking contrast between today’s therapeutic state and the nanny state of the past is the absence of popular opposition. On the contrary, opinion polls reveal substantial majorities in favour of measures currently under discussion, such as bans on smoking in public places and restrictions on advertising of ‘junk food’. Where is the campaign to uphold the rights of smokers in pubs and restaurants? Have we seen demonstrations demanding the right to eat junk food or indulge in binge drinking?

The tobacco, food and drink industries have become so demonised in the eyes of public opinion that they are reduced to defensive rearguard actions to limit the damage to their trade that is likely to result from further government restrictions. The success of the new ideology of public health can be measured by the fact that government ministers can indulge in (wholly disingenuous) postures that, in introducing further curbs on unhealthy lifestyles, they are merely responding to the clamour of public opinion.

The transformation in popular attitudes to interventionist public health policies is all the more remarkable given the dramatic expansion in the scale of such initiatives. The government is currently considering drastic measures to curtail smoking, to curb the consumption of ‘unhealthy’ foods, to increase levels of exercise and to restrict the consumption of alcohol. Given that, according to official statistics promoted with varying degrees of hysteria, around a quarter of the population smokes, more than one in three are overweight, 25 per cent are obese, most take insufficient exercise and many, particularly young people, drink too much alcohol, the achievement of government targets in these areas demands dramatic changes in lifestyle for a substantial proportion of the population.

It is also striking that whereas the health benefits of quarantine or seat belts are clearly evident – even to those who defy them – those associated with current policies are dubious and contentious. For example, the dangers of passive smoking have been the subject of academic debate for more than 20 years. (3) The current consensus that banning public smoking will save up to 1,000 lives a year is a triumph of propaganda over science. At least there is some evidence in this area: in relation to the health benefits of advertising bans and food-labelling regulations there is none at all.

The apparently unstoppable momentum of the campaign for a ban on public smoking reveals the key dynamics of the therapeutic state. Not only is it supported by non-smokers, but a majority of smokers also approve of a measure which will prevent them from pursuing this traditionally convivial activity in pubs, clubs and restaurants. This reflects the fact that many smokers have internalised the way in which smoking has been re-conceptualised in the public health campaigns of recent years. Up to the 1990s, smoking was generally regarded as a bad habit, if one that provided some respite from the cares of work and family life. This view of smoking was confirmed by the fact that, in response to mounting publicity about the link between cigarettes and lung cancer from the early 1960s onwards, several million people abandoned the habit. Furthermore, most did this without the benefit of any professional intervention.

In the 1990s however, the focus shifted from the activity of smoking to the personality of the smoker, who was now found to be an addict in the grip of a chemical dependency (on nicotine) and the dupe of cigarette advisers (‘a consumer inveigled into smoking by sophisticated and misleading marketing’, as the recent BMA report puts it).

The smoker is not only a pathetic loser, but is also to blame for polluting the atmosphere and for damaging the health of a lengthening list of innocent victims. A man who smokes is guilty of poisoning his family (reducing his own fertility, giving his spouse an increased risk of cancer, his children an increased risk of cot death, asthma and other respiratory disorders); he is also a menace to his workmates, and even to the non-smoking staff in public places that continue to tolerate this evil practice. The female smoker is guilty of all these crimes and worst of all, of damaging her unborn baby by continuing to smoke during pregnancy. Recent television adverts reinforce smokers’ guilt with children’s accounts of their parents’ deaths from smoking-related illnesses.

The smoker – addicted and duped, defiling and corrupting, morally defective and socially irresponsible – needs professional intervention. He or she needs medical treatment (in the form of nicotine replacement therapy or other medication to help overcome addiction), psychological and spiritual treatment (counselling or ‘support’, often combined with complementary therapies, help through the processes of withdrawal and rehabilitation).
The morose atmosphere in the smokers’ huddles that formed outside many workplaces in the 1990s confirmed the impact of the denigration of the smoker on smokers themselves. Far from being united in defiance of petty regulations, they were, like members of a therapy group, united only in their existential suffering, in their self-loathing, in becoming pariahs in a society dedicated to clean and virtuous living.

The proposal for a ban on smoking in public places in Britain was first made in 1988. Why has it taken more than 15 years for this measure to become a serious policy prospect? The growing popularity of the measure cannot be attributed to the growing strength of scientific evidence in support of it – this is just as weak now as it was then. Nor can it be attributed to any significant change in the enthusiasm of government for interventionist public health policies: Margaret Thatcher and John Major were just as keen on authoritarian health policies as Tony Blair.

The decisive shift that has paved the way for the advance of the therapeutic state is the enhanced sense of individual frailty and vulnerability that has resulted from the demise of politics and the decline in social solidarity over the past decade (4). The individuation and powerlessness experienced with a particular intensity by smokers have made them responsive to the redefinition of personal difficulty as a form of pathology that requires professional management. Hence they are receptive to any government measures that offer to provide help in overcoming their personal inadequacies – even though such measures may only compound their incapacity.

When smokers confessed that they welcomed bans on public smoking as a further measure to protect them from themselves, the public health zealots recognised the triumph of their bleak ideology (5). The stage was set for the leaders of the British Medical Association to march to Downing Street bearing aloft a banner in the form of a supersized cigarette packet carrying the legend ‘Passive Smoking Kills’. If the nanny state is a paper tiger, the therapeutic state is a much more formidable adversary, not least because so few even recognise it as an enemy.

Dr Michael Fitzpatrick is author of MMR and Autism: What parents need to know, published by Routledge, June 2004. Buy this book from Amazon (UK) or Amazon (USA)

(1) Nanny madness. What’s so terrible about the nanny state, anyway?, Guardian, 26 May 2004

(2) BMA response to the consultation: Choosing Health, British Medical Association, July 2004

(3) The tyranny of health: doctors and the regulation of lifestyle, by Dr Michael Fitzpatrick, Routledge, 2001

(4) Therapy culture: cultivating vulnerability in an uncertain age, by Frank Furedi, Routledge, 2004

(5) Public attitudes to public health policy, King’s Fund, 2004