What is healthism? (part two)

Apple and stethoscopeIn part one of this post I explained the most common meaning of healthism (an excessive preoccupation with healthy lifestyles and feeling personally responsible for our health) and described an authoritarian sense of the term. Here I discuss healthism as an appeal to moral sentiments and as a source of anxiety. I also note an unusual definition of the term as the desire to be healthy, which leads me to end with a personal disclaimer.

Moral healthism

The directive to be personally responsible for our health – whether it comes from a government health policy, the medical profession, or an advertisement – is often fraught with unacknowledged moral overtones. People who practice healthy lifestyles (daily exercise, a Mediterranean diet) and dutifully follow prevention guidelines (annual cancer screenings, pharmaceuticals to maintain surrogate endpoints for risk reduction) are overtly or implicitly encouraged to feel morally superior to those who do not. This includes the right to feel superior to those who ‘choose’ to be unhealthy – after all, isn’t smoking a morally indefensible choice? The implication is that those who fail to take responsibility for their health are undeserving of our sympathy or assistance (especially financial).

This quality of healthism – like the anti-authority healthism discussed in part one – is possibly more common in the US than elsewhere. It’s unfortunate but true that in the US there’s a tendency to blame the poor and disadvantaged for not being able to pull themselves up by their bootstraps. There is a decided unwillingness to acknowledge that differences in wealth and social class during childhood have lifelong effects on behavior and health.

As sociologist Marc Renaud writes:

One’s capacity to modify potentially pathogenic behaviours and to “stick with it” is directly related to one’s wealth, power, and education — in short to the degree of control one has over one’s future. The higher up in the social hierarchy, the more control one feels capable of exerting over life, the easier it is to change unhealthy habits. In other words, one’s “will to change” is largely predetermined by one’s social environment. To be told, by an education program or otherwise, that one’s life-style should change is neither helpful nor effective.

If a boy grows up surrounded by drug abuse, gang violence, and an abbreviated lifespan for the adult men in his life, it’s unlikely he’ll worry about the possibility of lung cancer 20 years from now.

In an attempt to slow escalating health care costs in the 1970s and ’80s, moral healthism was a convenient way for politicians — at least symbolically — to shift the burden of responsibility for health onto individual citizens. It remains a popular position among politicians who would like to blame high health care costs on those who allegedly eat too much. In addition to serving political interests, moral healthism is used by vendors of health-related goods and services to motivate consumers to make purchases (gym memberships, organic food, diagnostic screening).

When healthism refers to a superior moral attitude, the term is meant to be pejorative and disparaging. People who take pride in the nutritional correctness of what they eat, the size of their muscles, or the absence of any flesh that’s not firm may be examples of healthism in action, but those individuals would not use that term to describe their behavior. At most they might admit to being health and/or body conscious.

Anxiety healthism

Another quality of healthism is anxious preoccupation with health. If we believe we’re personally responsible for our health, it follows that we should worry about whether our behavior is sufficiently health promoting. This attitude is a favorite of pharmaceutical companies (“ask your doctor”) and the food industry (“heart healthy”). It’s also a natural by-product of medicine’s increasing emphasis, since the 1950s, on risk factors for disease.

Moral and anxiety healthism often overlap. When healthism is used by pharma, the food industry, the fitness industry, and the purveyors of medical products and services, there’s usually an element of both anxiety (you should be worried about your health) and morality (you can feel good about yourself if you do (or bad if you don’t)).

Anxiety about health is fueled by all forms of media, both through advertising and by the barrage of information on the latest (often contradictory) health findings. When media companies benefit financially from the public’s interest in and vulnerability to health information, they’re practicing anxiety healthism.

Historically, there may be a connection between the origins of healthism in the 1970s and anxiety. Robert Crawford suggests that the economic insecurities and uncertainties of the 1970s may have prompted efforts to control our health as a way to reduce anxiety. When we can’t control the world around us, we can attempt to keep anxiety at bay by increasing control over ourselves.

It’s only natural that we want to exert some control over our health, our susceptibility to illness, and the length of our lives, no matter which anxious decade we live in. Increased anxiety about health, however, makes us vulnerable to the promotion of lifestyle changes (and their associated consumer products) that will ‘guarantee’ good health. The obsessive pursuit of health, accompanied by anxiety, is in fact unhealthy.

Healthy healthism: Profiting from moral and anxiety healthism

Although it’s exceptional, some people use the term healthism to refer to the desire to be healthy (“Healthism – A Way to Become Healthy“). I’ve come across only two examples of this usage, one in India and the other in Canada. It’s a very ironic sense of the term, since it uses the moral, guilt-tripped compunction to be healthy to promote and profit from anxious, health-seeking behavior.

The president of the Healthism.com site in Canada (in an email exchange) agreed with me that healthism is about personal responsibility for health, but not that the term is pejorative. He believes those who are “marginalized” in society should be held to the same standards as the affluent when it comes to personal responsibility for health. To believe otherwise is “typical academic elitism.”

Healthism.com promotes diagnostic testing and promises to sell “doctor-reviewed products for your health and vitality.” While the site may choose to define healthism as the desire to be healthy, it’s an excellent example of practicing moral and anxiety healthism to profit from our vulnerability to health concerns.

What can I say? In a post-1984 world, people redefine words to mean their opposite all the time.

Disclaimer

Obviously, in just two posts, I haven’t exhaustively captured all possible meanings and nuances of the term healthism. People disagree, for example, about what it means to be personally responsible for one’s health. When Irving Zola first used the word healthism in 1977, his meaning was virtually identical to an early use of the term medicalization.

I will leave for later a response to the accusation that, because I find moral and anxiety healthism objectionable (I hope that’s obvious), this must mean I believe everyone should smoke, be overweight, and never be tested for cancer. (When discussing healthy lifestyles, I really do get this reaction from otherwise highly intelligent people.) That’s not what I think, but it would take more than a few posts to explain what I find so objectionable about personal responsibility for healthy lifestyles. It’s a sign of the effectiveness of the personal responsibility message that many people fail to examine the interests it serves. I myself was once in that category, which is one reason I feel so strongly about the subject today.

A preoccupation with healthy lifestyles to the point of healthism is a coping mechanism in an unhealthy world, just as smoking and substance abuse are mechanisms for coping with the stressors of modern life. It is not the practitioners of healthy lifestyles I find objectionable, but those who exacerbate and profit from our anxiety about health.

I write about the history of healthism because I’m interested in medical, political, economic, cultural, social, and historical factors that influence the way we think about health and health policy today. Changes in health policy cannot happen unless the public understands what ultimately determines health and illness. Healthism — personal responsibility for health by practicing healthy lifestyles — has had an enormous influence on the public’s perception of health. By turning our attention away from the larger social environment in which we live, healthism has reinforced biomedicine’s assumption that our understanding of health must be limited to the narrow confines of the laboratory and the doctor’s office.

Our financially and professionally entrenched system of medical care has a vested interest in maintaining an understanding of health that preserves the status quo. Part of the power of our biomedical culture, however, is that its contingency – the very real possibility that it could be different — is ordinarily invisible to us. What would it take to imagine a widely shared understanding of health that valued not only the quality and availability of health care, but daily living conditions that are conducive to everyone’s health? This is the question I hope an examination of healthism will provoke.

Related posts:
What is healthism? (part one)
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.

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2 Responses to What is healthism? (part two)

  1. A wonderful set of posts I have just discovered through your interaction with Doctor Skeptic. It was obviously impossible to cover all the bibliography on the subject, but I think Petr Skrabanek’s “The Death of Humane Medicine and the Rise of Coercive Healthism ” (full PDF googling the title) is one of the best discussions on the subject still around. It is still being used by many in Europe as a teaching textbook.

    • Thank you for finding my blog and leaving a comment. I too enjoy Doctor Skeptic. I didn’t mention Skrabanek because I have mixed feelings about him. I admire him for speaking out about this subject so incisively when he did. I have reservations about some of his opinions in ‘Follies and Fallacies in Medicine.’ I really should gather my thoughts on Skrabanek and write them up. His intellectual enemies accused him of being paid by the tobacco industry for his opinions. He appears to have had a very brave, independent mind, unafraid of controversy. I’m glad to hear that his work is still being taught in Europe.