Throughout history there’s been an understandable desire to find connections between our behavior and our health. Human beings have practiced health regimens involving diet, exercise and hygiene since antiquity. When medicine was based on the humoral theory of disease, for example, individuals were advised to purge the body in the spring and, in the summer, avoid foods or activities that caused heat. Bathing in ice water was recommended in the 19th century. Mark Twain quoted the advice: “the only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you’d druther not.”
In the second half of the 20th century many Americans adopted the idea that a ‘healthy lifestyle’ (diet, exercise, not smoking, etc.) was a good way to prevent disease and live longer. This particular attitude was a product of popular perceptions about health (a surge of interest in holistic/alternative practices, self-care movements such as Our Bodies, Ourselves) and prevailing social attitudes (such as desirable body images). Perhaps more so than in previous centuries, the growth of media consumption and the effectiveness of modern advertising allowed commercial interests (books, magazines, fitness merchandise, vitamins and supplements, weight loss pills, diet and energy foods, …) to exert considerable influence on health behavior.
Also at work was extensive media coverage of a presumed link between preventive lifestyles and risk factors for disease (conflicting opinions about salt and which type of fats to eat are good examples). Unlike the vague aphorisms of previous generations, this more modern source of health advice had the scientific backing of epidemiology, if not the proof that comes from randomly controlled trials.
One of the terms used to describe the enormous increase in health consciousness is ‘healthism.’ Judging from how I’ve seen the word used, it means different things in different contexts to different people. I’m going to describe a few of those meanings.
This post grew rather long, so I’ve divided it into two parts. In part one I discuss an anti-authority sense of healthism as well as healthism’s most common meaning: a sense of personal responsibility for health accompanied by an excessive preoccupation with fitness, appearance, and the fear of disease. Part two discusses the moralistic and anxiety-inducing qualities of the term, plus an odd use where healthism becomes another word for health itself.
Some people use the term ‘healthism’ to emphasize the imposition of health directives in an authoritarian manner. A prime example is the vigorous anti-smoking campaign waged by Nazi Germany in the 1930s. Supporters of smokers’ rights use ‘healthism’ in this anti-authoritarian sense when they object to limitations on the freedom to smoke whenever and wherever they please. When Frank Davis, a highly articulate smokers’ rights blogger in the UK, refers to ‘healthism,’ he is objecting to the infringement of his rights.
This anti-authority sense of healthism also gets used when referring to the advice that we should exercise more or give up our favorite foods simply because they contain excessive amounts of sugar, fat, and salt. I don’t know of any statistics, but I wouldn’t be surprised if this use of the term is especially popular in the US, a nation proud of its ‘don’t-tread-on-me’ tradition of rugged individualism.
Here’s an example of a patient resisting the health advice of an authority, described by a doctor writing in The New England Journal of Medicine:
After I had berated the patient for his obvious failure to comply with my recommendations to correct his “misbehavior,” he said, “You know, doctor, there is more to life than good health.” These words have helped me rein in my sometimes overzealous attempts to force patients into that glorious state of wellness and maintain a more realistic approach to the best possible state of health.
What distinguishes anti-authority healthism is the open acknowledgement that the injunction to be healthy is externally imposed. This differs from other versions of healthism where the pursuit of health is internally motivated and individuals have little or no awareness of the external origins of their motivation.
Healthism as excessive preoccupation with health
In 1980 Robert Crawford defined healthism as “the preoccupation with personal health as a primary – often the primary – focus for the definition and achievement of well-being; a goal which is to be attained primarily through the modification of life styles” (emphasis in original). He noted some of the signs of this emerging trend in the 1970s: A remarkable increase in the number of people exercising, jogging, and running. An aggressive anti-smoking campaign. The proliferation of popular health magazines. The increasing frequency of health-related subject matter in newspapers and magazines. Advertisements that appealed to the desire to be healthy, even when the product’s connection to health was entirely superficial.
In 1980, when preoccupation with health and fitness was new, it was remarkable. Today it is so prevalent that it’s almost invisible — we simply take it for granted. All around us are people who aspire to healthy lifestyles and hold themselves responsible for their health, and we don’t give them a second thought. (Healthism is all around us, yes, in the media, in advertisements, and on supermarket shelves. As far as individuals go, however, healthism is predominantly a white, middle-class phenomenon.)
Some changes in our behavior – exercise routines, for example – are no longer even associated with the pursuit of health. Other explanations have come to suffice: Self-discipline and control are virtues in themselves. Asceticism has an aesthetic appeal. Being fitter-than-thou provides moral superiority. We live, after all, in a consumer culture based on the promotion of self-image and the value of physical appearance. The change in our fitness behavior in the 1970s, however, was linked to the advent of healthism.
Why the time was ripe for healthism
How this transformation happened is a complex story that includes the history of medicine in the late 20th century. The status of the medical profession was in transition in the 1970s. Once the Western world had won the battle against infectious diseases, medicine was confronted with the prevalence of chronic disease. When immediate success on this front was not forthcoming, public confidence in medicine declined.
Highly vocal critics were ruthless in their eagerness to find fault with medicine: Ivan Illich (Medical Nemesis), Irving Zola (Disabling Professions), Eliot Freidson (Profession of Medicine), Thomas Szasz (The Myth of Mental Illness). There were many others who wrote in the popular press, influencing public opinion, whose names are less familiar today.
The decline in confidence in medicine was due in part to a general disillusionment that followed idealistic and unrealized hopes of the 1960s — the world did not turn out to be better place in the 1970s. All professions were subjected to harsh criticism, and medicine was no exception. There were also more specific forces at work, however, at least in the US. The implementation of Medicaid and Medicare, followed by managed care, had a major impact on the stature of the medical profession and on the dissatisfaction with health care among both doctors and patients. It seems reasonable to suggest that if there was a decline in both confidence in and satisfaction with medicine, the public may have been especially receptive to the idea that they should take responsibility for their own health by adopting healthy lifestyles.
The emerging economic and political climate at the time also contributed to the rise of healthism. After the exceptionally stable and prosperous post-WWII decades, the 1970s brought the oil crisis, the combination of double-digit inflation and high unemployment (stagflation), and a turn to the conservative, neoliberal right. In 1980, Ronald Reagan was about to begin his first presidential term. It was expedient to redefine health, access to health care, and unemployment as matters determined by the worthiness of an individual’s character. Self-help — the kind advocated by the promotion of healthy lifestyles — was preferable to government assistance.
Healthism’s legacy for social determinants of health
The political climate favored appealing to the individual even at the expense of society. Looking at the situation in 1980, Crawford believed that healthism’s emphasis on individual responsibility would turn out to be its most significant and unfortunate legacy. The message was: “I have only myself to blame if I fail to modify my behavior and subsequently suffer the health consequences.” Crawford foresaw that the elevation of the individual would work against the search for collective solutions to environmental and occupational threats to health.
Our understanding of the determinants of health has advanced considerably since 1970s concerns about the dangers of air pollution and the inhalation of asbestos on the job. There is now extensive evidence, for example, that health disparities are due to social class itself and not just lack of income or access to health care. The fundamental problem, however, is the one Crawford identified: By focusing on the individual and not the society in which the individual lives, medicine, the health care industry, and governments have failed to address the ultimate causes of disease.
Healthism contributed to this failure. Ironically, the explosive preoccupation with health in the late 20th century has been a formidable hindrance to achieving the improvements in health we claim to seek by practicing healthy lifestyles.
In part two of this post I discuss aspects of healthism that increase our anxiety about health and that appeal to a sense of moral superiority.
What is healthism? (part two)
The politics behind personal responsibility for health
Healthy lifestyles serve political interests
There’s more to life than the pursuit of health
The last well person
The tyranny of health
“Tyranny of health” on KevinMD
The tyranny of health then and now
From healthism to overdiagnosis
Paging Dr. Frankenstein
Old age and the limitations of a healthy lifestyle
The problem is you
“I” Is for Innocent: Health obsession in fiction
Why medicine is not a science and health care is not health
My personal odyssey through the health culture
The Health Culture: Yesterday. Today. Tomorrow.