The tyranny of health

Chocolate cakeSomething happened to the public perception of health and medicine in the 1970s. People began to adopt — and financial interests and the media began to profit from – “healthy lifestyles.”

This was not without consequences.

• Americans became increasingly preoccupied with diet, exercise, and health habits.

• There was a big uptick in the use of alternative “medicine” and stress reduction practices – acupuncture, chiropractic, herbalism, naturopathy, nutritional therapies, yoga, massage, biofeedback.

• The increase in news and advice columns on health and wellness made people more anxious about their health.

• The public sought medical care much more frequently for symptoms that would have been considered insignificant in the past.

Was “healthy lifestyles” a medical idea?

Health awareness and anxiety are nothing new. Throughout history people have been concerned about threats to their health. Bubonic plague killed 200 million people. The death rate for women who gave birth in the 19th century was 400 per 100,000 births, compared to 10 per 100,000 today.

Before the last century, physicians had very little to offer patients that would cure or prevent disease. This left the field wide open for quacks and charlatans, who could prey on health anxieties to sell their wares. By the late 20th century, however, modern medicine had a great deal to offer. Plus, it had won the confidence of the public – something medicine lacked in the days when the only “cure” was bloodletting or purging (the use of ultra-strong laxatives).

It seems reasonable to ask, then, if the emphasis on healthy lifestyles in the 1970s originated with the medical profession. Americans were living longer and suffering from the diseases of old age (cancer, heart disease, arthritis). Epidemiological research – observing the health and habits of citizens in various countries or ethnic groups – identified associations between lifestyles and diseases (eat yogurt and live to be 100, like the citizens of Georgia; eat soy products and avoid breast cancer, like the Japanese). One can easily imagine that the idea of telling people to be responsible for their health habits came from the medical profession.

But no, it did not.

The dark side of medicine

The emphasis on healthy lifestyles, although salutary in many ways, has a very dark side to it and has led to the increasing peril of a tyranny of health in the United States.

The quotation is from Dr. Faith Fitzgerald, writing in The New England Journal of Medicine in 1994. This was followed in 2000 by Dr. Michael Fitzpatrick’s book, The Tyranny of Health: Doctors and the Regulation of Lifestyle. There was also this statement from O. H. Forde of the Institute of Community Medicine in Tromso, Norway:

The moral and coercive crusade for increased risk awareness and purity in life style can too readily take on the form of cultural imperialism towards conformity. Epidemiologists and the health care movement in general have a mandate to fight disease and premature death: they have no explicit mandate to change culture.

Dr. Fitzgerald’s article in the NEJM addressed the down side – or, as she calls it, the “dark side” – of a medical climate that holds individuals responsible for their health. Such a climate assumes that those who are unhealthy have committed a crime against society. After all, society must pay their health care costs, whether it’s through Medicare and Medicaid, lost time from work, or treatment centers for substance abuse.

Society in turn will expect physicians to educate their patients, to eliminate their unhealthy behaviors, and somehow to coerce them into adopting healthy habits. A “tyranny of health” is bad for both patients and physicians.

What penalty should we impose on the irresponsible?

The push for healthy lifestyles came not from the medical profession, but from political, economic, and social forces of the 1970s and 1980s. It was presented to the public as the need to take “personal responsibility” for one’s health.

The shift in health responsibility from the state to the individual – known as “healthism” — was very successful. Medical journals today – as well as health advice columns — write about the importance of the individual’s behavior in preventing disease.

A recent commentary in the Journal of the American Medical Association asks: If individuals don’t use preventive services, “what kind of penalty … would be ethically and morally acceptable?” The question wasn’t “How do we account for unhealthy behavior,” but what punishment would be sufficient either to change that behavior or at least to save money by denying these people health care.

When “personal responsibility” is endorsed by the authority of the medical profession, we no longer see that healthism is a political position, not simply a medical opinion. And because we don’t see this, it doesn’t occur to us that our attitude towards our own health could have taken a different path. Perhaps it still should, though I’m not optimistic that it will.

Related links:
The tyranny of health then and now
“Tyranny of health” on KevinMD
Blogging: Time to get over it
Health insurance industry to consumers: You’re financially responsible for your behavior
Sanjay Gupta a victim of obesity myths?
My personal odyssey through the health culture
The Health Culture: Yesterday. Today. Tomorrow.
“I” Is for Innocent: Health obsession in fiction
The last well person


Image source: Under the ash tree

Faith T. Fitzgerald, M.D., The Tyranny of Health, The New England Journal of Medicine, July 21 1994, vol 331 no 3, pp 196-198 (subscription required)

Michael Fitzpatrick, The Tyranny of Health: Doctors and the Regulation of Lifestyle

O. H. Forde, Is imposing risk awareness cultural imperialism? : The ethics of epidemiology, Social Science & Medicine, 1998, vol 47 no. 9 pp. 1155-1159 (abstract only)

Robert H. Brook, Rights and Responsibilities in Health Care – Striking a Balance, The Journal of the American Medical Society, June 9, 2010, vol 303 no 22 pp 2289-2290 (subscription required)


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