1 September 1983
NO-ONE knows where good health comes from. The more you look, the less clearly you see. But in the last ten years there has been an upsurge of interest in the problem of how we can be healthy. The present vogue for health has many strands.
There is the official strand. Following pressure from the International Monetary Fund on the British Government to cut back public spending, the House of Commons Expenditure Committee recommended that money could be saved through more prevention of illness, especially through self-help. The present Conservative Government has followed the Labour Government in spending ever larger sums on anti-smoking and physical fitness health education campaigns. Guilt is the core of the method. The smoking pregnant women has now to contend with the knowledge she is also killing her baby.
Then there is the popular strand: running, swimming, keep fit, dieting, aerobics. There are TV programmes, abundant advice in the newspapers and on the back of cereal packets, hundreds of best. selling books, thousands of classes and a boom in shorts and running shoes. Exercise clothes and everyday fashion are becoming increasingly indistinguishable. Footless tights, running shoes and track suits have all been incorporated into what we wear normally. Then there is the strand that comes from criticisms of Government policy and ruling ideas. Health cannot be improved by individual action, we argue. Look at the factories and the housing estates. It is noise, noxious chemicals, accidents at work, pollution from cars and industry, lead in the air, junk food, high in salt, sugar, fat and chemicals. It’s damp and overcrowded housing and the isolation of tower blocks. It is shiftwork, exhaustion and the strain and isolation of looking after young children. It is unemployment. It is not having the money to buy decent food, holidays, heating and adequate housing. It is living with chronic stress, at work and at home. It is not being able to give up smoking, drinking or cut down on over-eating because our society generates too many pressures. The whole organisation of work and domestic life damages our health.
Today, the view that much ill health, particularly cancer and heart disease, could be avoided by changes in lifestyle has become so widespread it is regarded as themselves a disservice. They also burden the community with the cost of caring for all this self-inflicted disease.
Care in Action, the Conservative Government’s policy statement on the health service published in 1981 puts it this way: ‘The prevention of mental and physical ill health is an area in which the individual has clear responsibilities. No-one can wholly escape illness or injury, but there are plenty of risks to health which are within the individual’s power to reduce or avoid. Too many endanger their health through ignorance and social pressures’. The argument becomes most horrible when it is used to account for the vast class differences in death rates and levels of illness in society. Even the crudest statistics reveal the pattern: if you live in a council house and don’t own a car you are nearly twice as likely to be dead before you reach 65 than if you are an owner-occupier in a two-car household.
The view that the lower classes are killing themselves through over-indulgence and self-abuse is the prevalent explanation for the class pattern of ill health in medical circles.. Doctors moan that their working class patients will not give up smoking or change their eating habits. Even the Labour Government defined the problem as one of ignorance.
The 1977 White Paper Prevention and Health talked authoritatively of the ‘problem of communicating effectively with people in social classes four and five’. And it’s an argument which suits the Conservatives down to the ground.
But this approach to ill-health —blaming the victim — completely absolves food manufacturers, polluters, employers and landlords of their part in destruction of health. And it makes no attempt to understand why — in a society where there seems no hope for the future — people sometimes choose to drink, smoke, eat what they feel like and sit in front of the telly.
Knowledge about what makes us ill is based on studies correlating our ill health with our exposure to certain foods, chemicals, noxious substances in the air, housing conditions and so on. This has yielded remarkable and thought-provoking results. We now know, for instance, that at least 75 per cent of cancer is environmental in origin, and therefore — in principle —preventable. But it is also increasingly clear that the quality of our general health cannot be simply reduced to the extent of our exposure to specific measurable environmental nasties.
For example, one study of civil servants’ heart attacks found there were four times as many deaths among men in low-paid jobs like porters and messengers, than among senior bureaucrats. True, men at the bottom had smoked more and taken less exercise than the men at the top. But even when this was taken into account, three in four deaths of the men at the bottom remained unexplained. There was something else going on.
It has been known for hundreds of years that whether we get ill is not only dependent on the pathogens we are exposed to, but our body’s resistance. If you are run down you get everything that’s going. What factors bear on our levels of resistance, however, gets far less discussion than it deserves. But exhaustion, boredom, powerlessness and loneliness emerge again and again.
Health is not a virtue. A look at our present society reminds us that health is not only an attribute of the just. The people at the top — the most senior civil servants, the judges, the university professors, the doctors and leading businessmen, the controllers, decision makers and exploiters — have by far the best health. And it is an unpleasant thought that the reason for this is much more likely to do with their power — their job satisfaction, sense of control over their lives, emotional support from wives and secretaries, time for leisure and recreation — than with foregoing the pleasures of the flesh.
So the notion of health an entity in itself dissolves. And we are left with everyday life. The routes to better health cannot be distinguished from what we want anyway: control over our lives, satisfying work, excitement, time for recreation, space for personal autonomy, opportunities for supportive and loving relationships, decent food, a non-toxic environment, holidays, space for children to play, warm and unclaustrophobic housing. There are no short cuts to the healthy life. It is back to the old political dilemmas about what kind of social change we want and how to make it. It is a social movement which is both encouraging and frightening. Encouraging because it shows that people haven’t given up on trying to change their lives. It’s frightening because the diet/smoking/lack-of-exercise view of illness is winning hands down.
As the crisis deepens, the forces damaging our health — through unemployment, alienating work, low incomes, loneliness, and fear of violence —are becoming stronger. Yet the dominant explanations for our troubles lead us away from examining society and towards ever greater self blame.