Public health and the obsession with behaviour
ESSAY: Recent thinking on health policy has been driven by two myths: that bad health is caused by bad habits, and that government can promote good health by changing our behaviour.
In the run-up to the UK General Election, spiked is publishing a series of essays reposing political issues. The aim of the ‘Question Everything’ essays is to encourage people to rethink the past, the present and the future. In this eighth essay, Dr Michael Fitzpatrick says that in the sphere of health the Tories are planning to replace New Labour’s ‘nanny state’ with a ‘nudge state’ – a development which would damage our liberty and dignity even further.
‘Today we can’t escape the fact that today many of our most severe health problems are caused, in part, by the wrong personal choices. Obesity, binge-drinking, smoking and drug addiction are putting millions of lives at risk and costing our health services billions a year. So getting to grips with them requires an altogether different approach to the one we’ve seen before. We need to promote more responsible behaviour and encourage people to make the right choices about what they eat, drink and do in their leisure time.’ (David Cameron, foreword, A Healthier Nation, Policy Green Paper No.12, Conservative Party.)
Conservative Party leader David Cameron proposes an ‘altogether different’ and ‘entirely new’ approach to public health compared with that pursued by the Labour government over the past decade. In his foreword to the policy green paper that provides the basis for the Conservative Party election manifesto commitment to relabel the Department of Health as the Department for Public Health, Cameron emphasises that ‘we must think practically about how to help people to take more responsibility for their own health’. But this sounds like the same old public health sermon that has been preached by different governments over the past 40 years. Indeed, the Labour Party manifesto proclaims a similar commitment to ‘preventative health care’, insisting that ‘we all have a responsibility to look after our own health, supported by our family and our employer’.
So, what is new and different about the Conservative approach to public health? The central theme of A Healthier Nation is that Tory policy will be guided by ‘cutting-edge science and research’ in the spheres of ‘social psychology and behavioural economics’ (or alternatively from ‘cognitive science and behavioural psychology’, all terms are readily interchangeable). Official resort to the latest psychological fad (usually imported from the US) is not particularly novel: this has been a key feature of a range of New Labour therapeutic initiatives, including Sure Start parenting programmes, the ‘We Need To Talk’ campaign for ‘improved access to psychological therapies’, and the promotion of ‘social and emotional aspects of learning’ in schools. But before looking more closely at the politicians’ preoccupation with the use of psychological techniques to manipulate behaviour, let’s first consider some of the assumptions underlying Cameron’s public health policy.
The myth of a public health crisis
The notion that deviant individual behaviour is a major cause of disease is central to contemporary public health and it is endorsed by all the big political parties. But is it true? The most striking change in the health of the nation in the years that I have been a general practitioner in London has been increasing longevity. Last year, the practice I am part of welcomed three more patients as centenarians. It is extraordinary that our ageing patients have not only survived numerous threats to decimate the nation (AIDS, BSE, SARS, bird flu, pandemic flu), but they have also lived through decades of steadily rising obesity and alcohol consumption. No doubt the decline in smoking from the 1960s onwards has saved many from a premature death, but even the persistence of a hard core of smokers has not deterred the general improvement in both the duration and quality of life of older people.
Closer inspection of the behaviours chosen by David Cameron as major contributors to the burden of ill-health reveals a highly arbitrary selection. In the mounting panic about obesity over the past decade, both the scale and consequences of individual weight gain have been grossly exaggerated. There are relatively small numbers of individuals whose weight is a serious threat to their health, but for the vast majority of people who are moderately overweight, this is unlikely to have significant consequences for their health. Though some young people may drink excessively and cause a public nuisance, this is more a matter for the licensing and public order authorities than for doctors. There has been an increase in alcohol-related liver disease and other problems associated with prolonged high consumption, but these are still on a much smaller scale than in other European countries. Drug addiction is another social problem – but a much smaller one – and in my 20 years in an inner-city practice, one that has not significantly increased in size.
Furthermore, the links between particular diseases and the deviant behaviours identified by Cameron are weak. For example, it is widely assumed that coronary heart disease is strongly linked to ‘unhealthy diets’ and obesity. Yet the number of deaths from heart attacks has been steadily declining over the past 50 years – during which diets high in supposedly lethal sugars, fats and salt combined in all sorts of so-called ‘junk foods’ have become increasingly popular. These are also the decades of the couch potato, in which people are supposed to have assumed sedentary lifestyles and shunned physical exertions. It is clear that factors other than diet and exercise, notably genetics, possibly infections, are more important than behavioural contributors to heart disease. It is true that, as people live longer and die less from circulatory diseases, more people seem to be getting cancer. But, apart from lung cancer, the mortality from which has been declining for decades, no other common cancer is strongly associated with a behavioural cause.
How then can we explain Cameron’s selection of ‘our most severe health problems’ on which public health policy should focus? Why not, for example, choose some of the neurological and rheumatological problems, such as Parkinson’s disease, Alzheimer’s, multiple sclerosis, rheumatoid arthritis, connective tissue disorders and many more that constitute a substantial disease burden for our ageing population and a major challenge for the National Health Service (NHS), both in hospitals and in primary care? Why not, for another example, focus on chronic mental illnesses, such as schizophrenia and bipolar affective disorder, which affect large numbers of people and have major consequences for affected families and the wider society?
It is evident that Cameron’s choice has little to do with health, but is more a political selection arising out of prejudice against the sorts of people who engage in the sorts of activities that would be increasingly stigmatised under a new Tory government (as indeed they have been under New Labour). People who are overweight, appear drunk in public places, smoke cigarettes, use heroin, have become objects of public disgust and professional condescension and would remain so under a Cameron government.
The failed assault on behaviour
In their emphasis on links between behaviour and disease, politicians assume that public-health authorities have reliable techniques for achieving the behaviour changes they believe will improve the health of the nation. But this is a triumph of wishful thinking over experience. For at least half a century – longer in the US – doctors and other health professionals have been telling patients that their health would benefit from eating less and exercising more. This has clearly been a spectacularly unsuccessful intervention in terms of influencing diet and activity (though, as we have seen, this has not deterred dramatic improvements in health).
Take a more specific health-promotion intervention: the drive to persuade children to eat ‘five a day’ portions of fruit and vegetables. Despite nationwide propaganda and major school-based programmes promoting this policy, the proportion of children reaching this target has remained steady at around one in five over the past five years, after an earlier increase. But not to worry! Recent research shows that ‘five a day’ confers only marginal benefits in terms of cancer prevention – confirming earlier studies casting doubt on wider health benefits (see Bofetta et al).
The focus of government health policy on behaviour reflects a wider transformation of the relationship between the state and the individual. The concept of behaviour is traditionally associated with children and animals, often in the context of psychological experimentation. In place of the active subject of democratic citizenship, the behavioural approach assumes an individual who is the passive object of official policy. Instead of an independent agent playing an active role in society, the citizen is assumed to be ignorant and immature, requiring expert professional guidance. The self-determining individual is reduced to being the target of official propaganda and political manipulation.
In his book Dread, American public health researcher Philip Alcabes traces the origin of the contemporary culture of public health back to the response to the emergence of AIDS in the 1980s, which he characterises as the first ‘behavioural epidemic’: ‘The turn from risk group to risk behaviour was a sign of an important change in thinking, a behavioural turn, wherein behaviour as risk became behaviour as cause. Before the advent of AIDS, never had the entirety of disease prevention policy been to tell people what they should stop doing… In the AIDS era, behaviour control was disease control.’
Alcabes shows how this approach led to the ‘new moralism’ of safe sex – and the neglect of the various forms of blood-borne transmission of HIV, which offered no scope for moralising.
Alcabes also shows how the ‘behavioural turn’ in response to a real infectious disease in the 1980s was consolidated in response to ‘imaginary epidemics’, such as ‘bioterrorism’, from the 1990s onwards. He singles out the obesity scare as the archetypal postmodern ‘epidemic’ which ‘plays on fantasies of mayhem and misgivings about our habits’. Depicted as ‘the fault of individuals’ poor choices, the failure to opt for the healthy lifestyle’, obesity is ‘an easy canvas on which to paint our psychic unease, our difficulties in achieving personal goals, or our sense that we have become lazy – even though no study on the topic of body mass and psychic impairment shows any clear connection’. Nevertheless, the panic over childhood obesity has contributed to the notion of childhood as ‘a period of both intense vulnerability and grave toxicity to society – despite the lack of evidence of widespread harm’. The concept of childhood obesity as an epidemic or risk leads us to ‘create administrative solutions to manage our children’s behaviour’.
Nudges and networks
The distinctive feature of Conservative Party’s approach to public health is its acknowledgement of the failure of past attempts to change behaviour in the cause of health (of course, these are associated with the years of New Labour government). Thus, the Tories’ public-health Green Paper endorses recent judgements by medical authorities that propaganda on the dangers of drinking alcohol has been ineffective. The familiar response to (numerous) studies revealing that health promotion policies do not achieve their objectives is to demand more of the same and that everybody involved should try harder – while also proposing more coercive interventions, such as more punitive taxation, more bans and proscriptions. But while there are plenty of such proposals in the Conservative document, its claim to novelty is its reliance on the insights of recent popular psychology books such as Connected: The Amazing Power of Social Networks and How They Shape Our Lives and Nudge: Improving Decisions About Health, Wealth and Happiness.
The sole insight of Connected, the joint work of a Harvard physician and a Californian political scientist, is that individuals are influenced by social factors: ‘People do not have complete control over their own choices.’ But the authors’ ‘social network’ perspective treats individuals as passive objects who receive and transmit behaviours as though they were an infectious virus (though even the spread of the most infectious virus is influenced by specific individual and social factors). The results of supposedly groundbreaking academic inquiries appear banal. For example, the authors tell us that ‘psychological research suggests that feelings of loneliness occur when there is a discrepancy between our desire for connection to others and the actual connections we have’. Or in other words, ‘people with more friends are less likely to experience loneliness’.
When it comes to practical measures, the authors boldly propose ‘a new foundation for public health’ that offers Weight Watchers and Alcoholics Anonymous as models. One of their few specific proposals is a ‘creative alternative’ to current vaccination policy based on immunising ‘the acquaintances of randomly selected individuals’. This strategy is based on a mathematical model that suggests that ‘acquaintances have more links and are more central to the network than are the randomly chosen people who named them’. The authors suggest that ‘a choice informed by network science could be 700 per cent more effective and efficient’. But this model takes no account of the fact that most immunisations are aimed at a highly selected population (mainly babies) who have a very limited circle of ‘acquaintances’.
The concept of Nudge, written by a behavioural economist and a law professor based in Chicago, is that governments and employers should make self-conscious efforts to steer the choices of their citizens and workers in ways that improve their lives. They describe themselves as ‘liberal paternalists’ who reject bans and mandates in favour of ‘weak, soft, non-intrusive’ measures to create a ‘choice architecture’ that can ‘influence people’s behaviour in order to make their lives longer, healthier, and better’.
The most familiar illustration of this approach is the fly incorporated into the ceramic of airport urinals, providing careless men with something to aim at – and thereby at a stroke reducing ‘spillage’ by 80 per cent. However, the relevance of this example to the subsequent discussion of the Medicare subsidy for prescription drugs and the controversy over explicit consent or mandated choice in relation to organ donation is not readily apparent. The ‘nudge’ that appears most appealing to Tory public health strategists is the ‘dollar a day’ scheme piloted in North Carolina, under which teenage girls receive $1 for every day that they avoid becoming pregnant. A programme along similar lines in the UK offers pregnant women supermarket vouchers (exchangeable for any commodity but alcohol and tobacco) in return for abstinence from cigarettes: early results suggest that this is both cheaper and more effective than established ‘smoking cessation’ programmes that rely on ‘nicotine replacement’ and group therapies. Such crass economic incentives are more likely to invite fraud than produce long-term changes in behaviour.
In A Healthier Nation, Conservative public-health advisers claim that ‘there are some hugely successful strategies now emerging from cognitive science and behavioural psychology’. Perhaps they have in mind the theories of ‘positive psychology’ promoted by the psychologist and self-help guru Martin Seligman. These theories enjoyed a major influence in the era of speculative finance capital in the US, in what Barbara Ehrenreich refers to as ‘the decade of magical thinking’. These are the sort of notions used to justify charismatic leadership in corporate rulers and to help them in ‘managing the despair’ of the millions of workers who lost their jobs in restructuring (aptly satirised by the character played by George Clooney in Up in the Air).
It is ironic that at the very time that ‘positive psychology’ began to be imported into the UK – under the authority of New Labour happiness tsar Lord Richard Layard – its influence reached a ‘manic crescendo’ in the US subprime mortgage crisis that triggered the global financial collapse of 2007. A similar combination of self-delusion and wishful thinking of the sort that united creditors and debtors and dragged the world into recession is now offered in another package of cod psychology, as a model for public health.
#1: Frank Furedi on education
#2: Brendan O’Neill on immigration
#3: Mick Hume on left and right
#4: James Woudhuysen on innovation
#5: James Panton on the welfare state
#6: Jennie Bristow on parenting
#7: Brendan O’Neill on freedom
#8: Dr Michael Fitzpatrick on public health
#9: Sean Collins on capitalism
P Basham, J Luik, Fat kids? Obesity: epidemic and myth, Democracy Institute, 2009
M Gard, J Wright, The Obesity Epidemic: science, morality and ideology, Routledge, 2005
P Campos, The Obesity Myth, Gotham 2004.
P Boffetta, E Couto, J Wichmann et al, ‘Fruit and Vegetable Intake and Overall Cancer Risk in the European Prospective Investigation Into Cancer and Nutrition (EPIC)’, Journal of the National Cancer Institute, 6 April 2010
B Ehrenreich, Smile or Die: How Positive Thinking Fooled America And The World, Granta, 2009
R Thaler & CR Sunstein, Nudge: improving decisions about health,wealth and happiness, Penguin, 2009
N Christakis, J Fowler, Connected: the amazing power of social networks and how they shape our lives, Harper 2010.
P Alcabes, Dread: how fear and fantasy have fuelled epidemics from the black death to avian flu, Public Affairs, 2009.
‘A Healthier Nation’, Policy Green Paper No.12, Conservative Party
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