The open-air health scare

Been to the doctor’s lately? Why on Earth not? There’s sure to be something wrong with you – especially if you’re the sort of person who isn’t making the effort to get along to the surgery on a regular basis.

Never mind; the doctor will reel you in sooner or later, for a check-up on something or other, if for no better reason than to tick the box and claim the credit that comes from a closer relationship with you, the soon-to-be-sick punter. In the meantime, the Department of Health has licensed a little light stalking by some on-message GPs and put it all on the telly, in the form of Street Doctor (BBC1, Thursdays). The eight-part series involves four smiley medics touting for business on the streets of a major city. First it was Liverpool. Last week it was Glasgow. This week, they’ll be in Belfast.

As public health initiatives go, it’s cutting edge stuff: pushing the prevention message at the level of the pavement, where ordinary everyday lifestyles flourish in all their florid pathology. As trusted ‘agents of persuasion’ (1), GPs have been roped in to tackle ‘the rising tide of disengagement and disconnection from the public realm’ that is the elephant-in-the-room of all policy debate today (2). Operationally, Street Doctor promotes the kind of innovation and immediacy that is the antithesis of acute, hospital-led medicine, where big systems are notoriously resistant to change. The oft-repeated cliché about the need for a National Health Service, as opposed to a National Sickness Service, seems nowhere closer than in this series of eight programmes.

And for all these reasons, it stinks: because of its bullet-point didacticism, of a kind that would make Mao blush; because of the mock-sincerity of the GPs, who sidle up to ordinary people in the street like a hard-up hooker looking for action, and then proceed to inveigle their way into the inner lives of previously autonomous individuals; and because of the fatuous fancy that ‘barefoot’ doctoring can be doled out on the hoof, by a physician fresh out of the Sesame Street School of Public Health.

But the real significance of Street Doctor is subtler, and more pernicious. This is its implicit attack upon the public/private distinction that traditionally informs medical practice. The ‘unique selling point’ of Street Doctor is how the action really does take place on the street, complete with passers-by, onlookers, traffic and noise. Unabashedly alfresco, this is the doctor-patient relationship as performance art, modelling self-care as a wee morality play in which we are all invited to acknowledge our own infirmity. With a bottomless bag of tricks to hand, almost anything can be investigated, there and then. Lying down, sitting up, taking blood, listening to lungs, injecting drugs, looking into eyes, examining x-rays – who needs a clinic for all that?

Well, anyone who is truly sick, for a start. But, of course, this isn’t the target audience. This show is aimed at the majority of ordinary people for whom ‘health literacy’ remains a luxury spend. As primetime ‘edutainment’, Street Doctor popularises the idea that sickness is more common than you know. All that’s required are four GPs to lurk around a city centre to bring the pathology out into the open, for all to see. Which, of course, tells the viewer that they too might be less robust than they originally thought. ‘I’ve failed’, says one poor chap, found to be in possession of a deviant body mass index (BMI). Haven’t we all!

All this has happened before, in the 1930s, when the ‘health’ metaphor was no less promiscuously deployed. One famous study ‘discovered’ that of a cohort of almost 4,000 ordinary individuals – ‘among whom there was no problem of poverty [or] permanent unemployment’ – ’90 per cent had one or more pathological disorder’ (3). The report ‘revealed’ that ‘69 per cent were unaware of there being anything wrong with them‘. The solution, for the Pioneer Health Centre in Peckham, south London, was to tell them what was wrong with them: to tell them of the ‘factors in modern life that hinder and frustrate the development of the family’, the better to revitalise the ‘social soil’ which in ‘modern urban conditions… is in an advanced stage of erosion.’

Sound familiar? It’s the default setting on our contemporary cultural dial. ‘Modern life’ is increasingly viewed in toxic terms, with medicine promoted as the cure. As ‘the world’s biggest “army for good”, employing more than 1.33 million people’ (4), the NHS spearheads a postmodern crusade against the ‘bad’ – as identified in an endless stream of sermons from the mount of Whitehall. What this really means is pushing medicine into the political foreground in the hope that it will heal the public sphere. At which point, of course, a doctor isn’t just a doctor, to whom we turn when our body lets us down, in private and in confidence. Instead, the doctor is an ‘agent of persuasion’ charged with the dissemination of a whole new ethic of healthcare, in which looking after our bodies is configured as the height of personal responsibility, and neglecting our bodies a secular version of original sin.

Informal, open-ended, open-aired, and apparently undocumented, TV’s Street Doctors seem to be offering something radically different from the increasing bureaucratic mess of the NHS. ‘No appointments, no waiting, the doctors are coming to you’, they say. All of which suggests that Street Doctor is swimming against the tide and bringing primary healthcare to the people, unhindered by red tape and fire-breathing receptionists.

What is being modelled in Street Doctor, though, is not access to, or availability of, a service, but risk consciousness; the ubiquity of pathology and the virtue of awareness. Bringing one’s inner state into line with an outer norm is being sold as public duty – ‘nothing’s too private or too personal’. At a time when we all expect to live longer and freer from disease than ever before, we nonetheless are being invited to imagine the worst, to listen to the demands of the organism – fickle beast that it is – and organise our existence in terms of those demands. Sitting at home on the couch, waiting for EastEnders to start, the theatricality of Street Doctor is a coy cover for a serious message, of the body as public property.

And the tragic truth of the matter is that this approach is indeed working, at least for government. Few people complain about the non-stop ‘advice’ on how we should live our lives. Street Doctor slots easily into the schedules, alongside all the other ‘advice’ about health, diet, bodies and the like. ‘Your lifestyle is a disgrace’, scream the programmes. ‘No wonder you score so low on the happiness index: you haven’t had a check-up; you’re obese; you smoke; you’re inadequate as a parent; you don’t eat five-a-day!’ Compared to the Pope, who struggles to fill his homily-quota, the government has a free hand to pronounce on the most intimate aspects of our existence in the most moralistic of terms.

It used to be the other way round. Your body was your own business, not least of all because the body was identical with the self, which was, by turns, a role within a particular sort of social order. Strip-mine the social order, though, and the sanctity of the body looks less obvious. Indeed, take away the normative force of democratic liberalism and the body begins to look much more significant, as a site of authentic experience like no other. Grungy teenagers have long understood the rebellious appeal of the body, as irreducible, undetermined individualism. Sadly, the government seems to have bought into this self-same, solipsistic outlook, in which the body is the beginning and end of meaningful existence, precisely because the wider horizon looks so empty.

It should be up to the individual to decide when and how he or she is sick, not for the state to come looking for sickness.

(1) ‘Agents of persuasion’? Just say no, by Dr Michael Fitzpatrick

(2) Telling it like it could be: the moral force of progressive politics, Douglas Alexander, The Smith Institute 2005

(3) Observations on the Population Question: A Memorandum presented to the
Royal Commission of Population, Pearse Pioneer Health Centre, Peckham 1944

(4) Doctor and nurse numbers on the up, John Reid, Department of Health 2005