The original “Tyranny of Health” article that I wrote about – published by Dr. Faith Fitzgerald in The New England Journal of Medicine in 1994 — is no longer available online in its entirety without a subscription. I plan to discuss it in more detail in the next post.
Here’s a rather lengthy response I wrote in reply to someone at KevinMD who asked: “In what way did the state turn over its responsibility of individual health to the individuals?” I’ve said these things before, both on this blog and elsewhere. It seems to be one of my pet topics.
What happened to health in the seventies?
I started blogging two years ago because I wanted to answer precisely this question. I started wondering: How did we end up living in a world where there is so much information on health (much of it contradictory from one day to the next), where we feel personally responsible for our health, where we blame our own poor “lifestyle” habits if we get sick, where we judge the health lifestyles of others and are so proud of our own healthy habits?
Why did medicine and ideas about health change in the 1970s? Prior to that time, the policies of the Kennedy and Johnson administrations had assumed the state should be responsible for the health of its citizens. We had the Great Society programs, which created Medicare and Medicaid. When political and economic thinking became more conservative in the 1970s and 1980s, governments began to promote the idea that individuals were personally responsible for their health and should practice healthy lifestyles. This new message appeared in the Canadian Lalonde report of 1974 and the Surgeon General’s Report of 1979 (“Healthy People”).
Becoming personally responsible for our health
A large segment of the population – mainly the educated and economically secure – welcomed these ideas. Feeling personally responsible for one’s health and practicing healthy lifestyles gives one the reassuring illusion of control. In particular, it’s a good distraction from the things that are beyond individual control, like salmonella in our peanut butter and the antibiotic resistant superbug MRSA at the gym.
I was caught up in the healthy lifestyles attitude myself. When I look back, I could kick myself for not recognizing what was going on. Public opinion could have been rallied to support those health issues that need government backing – workplace safety, a healthy environment, an equitable distribution of access to affordable health care. But politics took a different path and the public went jogging.
I have nothing against healthy behavior and the concept of prevention. What bothers me is misleading the public for political purposes. Aside from smoking, the evidence for changing behavior is slim – either it doesn’t last (obesity) or, in some cases, it turns out to be wrong (all fats are unhealthy, fruits and vegetables prevent (all) cancers, HRT).
Does prevention work at the level of the individual?
A cause and effect relationship between a healthy lifestyle and disease prevention (healthism) has not been established by scientific evidence. There is a strong suspicion that those who practice whatever prevention lifestyle is currently fashionable are better educated, more affluent, and initially healthier than those who do not. Disease prevention is as much an issue of social and economic inequality as it is a matter of healthy lifestyles. To argue that those who become sick should be denied insurance because, after all, their behavior and thus their health was under their control, is not worthy of an egalitarian society.
Are we really free to choose?
The foods we choose to eat may be a matter of personal responsibility, but the emphasis on freedom of choice ignores the billion-dollar marketing environment in which we make those choices. And it’s not just advertising. We’re not free to choose if we’re unaware of the enormous financial power the food industry wields behind the scenes, where it influences Congress, the FDA, universities, and nutritionists.
The food industry has intimidated those who might speak out by threatening and instigating lawsuits. When Oprah Winfrey made a public comment on beef in a conversation about mad cow disease, she was hit with a $10.3 million class-action suit from Texas cattlemen. She won the case, but her legal fees were said to exceed a million dollars.
The Center for Consumer Freedom, an organization that promotes the interests of the restaurant and food industries, has as its slogan: “Promoting personal responsibility.” This is an example of healthism. Healthism promotes personal responsibility for health as a way to avoid the social, environmental, and (primarily) economic factors that affect our health. It assumes everyone can adopt “healthy lifestyles” without acknowledging the difficulty of changing behavior. It also has an unfortunate tendency to blame the victim when disease develops.
At first glance, it seems obvious that healthy lifestyles are in our interest. And they are. But when one segment of the economy prospers at the expense of national health, we should identify and openly discuss the tactics employed behind the scenes. Only then will we be free to choose.
And here’s a quotation I posted in the comments at KevinMD on the subject of the scientific validity of preventive health measures – or more broadly, the reliability of medical research. It’s from an excellent article in The Atlantic by David H. Freedman, author of Wrong: Why experts* keep failing us — and how to know when not to trust them. (emphasis added)
In poring over medical journals, [Dr. John Ioannidis] was struck by how many findings of all types were refuted by later findings. Of course, medical-science “never minds” are hardly secret. And they sometimes make headlines, as when in recent years large studies or growing consensuses of researchers concluded that mammograms, colonoscopies, and PSA tests are far less useful cancer-detection tools than we had been told; or when widely prescribed antidepressants such as Prozac, Zoloft, and Paxil were revealed to be no more effective than a placebo for most cases of depression; or when we learned that staying out of the sun entirely can actually increase cancer risks; or when we were told that the advice to drink lots of water during intense exercise was potentially fatal; or when, last April, we were informed that taking fish oil, exercising, and doing puzzles doesn’t really help fend off Alzheimer’s disease, as long claimed. Peer-reviewed studies have come to opposite conclusions on whether using cell phones can cause brain cancer, whether sleeping more than eight hours a night is healthful or dangerous, whether taking aspirin every day is more likely to save your life or cut it short, and whether routine angioplasty works better than pills to unclog heart arteries. …
Doctors may notice that their patients don’t seem to fare as well with certain treatments as the literature would lead them to expect, but the field is appropriately conditioned to subjugate such anecdotal evidence to study findings. Yet much, perhaps even most, of what doctors do has never been formally put to the test in credible studies, given that the need to do so became obvious to the field only in the 1990s, leaving it playing catch-up with a century or more of non-evidence-based medicine, and contributing to Ioannidis’s shockingly high estimate of the degree to which medical knowledge is flawed. That we’re not routinely made seriously ill by this shortfall, he argues, is due largely to the fact that most medical interventions and advice don’t address life-and-death situations, but rather aim to leave us marginally healthier or less unhealthy, so we usually neither gain nor risk all that much.
Image source: elLf houSE
David H. Freedman, Lies, Damned Lies, and Medical Science, The Atlantic, November 2010
David H. Freedman, Wrong: Why experts* keep failing us–and how to know when not to trust them *Scientists, finance wizards, doctors, relationship gurus, celebrity CEOs, … consultants, health officials and more