Continued from the previous post, where I noted that the Lalonde report — despite its good intentions — was followed by an emphasis on healthy lifestyles and personal responsibility for health, as well as increased health care costs.
Personal responsibility and social class
In Why Are Some People Healthy and Others Not?, Marmor et al, writing in 1994, were disappointed that the Lalonde report had not effectively prompted governments to address the underlying causes of health and disease. One reason for this, they believed, was that health policy reflects public opinion. If the public holds traditional views on what makes us sick (pathogens), what prevents disease (medical care), and what we can do to be healthy (take personal responsibility), new policies that include social determinants are unlikely. Those who are on the forefront of professional, scientific opinion may very well understand the importance of social determinants, but public opinion changes slowly. Without an education program, such as the relatively successful anti-smoking campaign, the public is unlikely to endorse change.
This is certainly true, although I believe there’s also something more fundamental at work here, namely, how a society accounts for the different life outcomes of its citizens. In Unequal Childhoods: Class, Race, and Family Life, Annette Lareau describes the assumptions people make when they hold others personally responsible for their life circumstances.
Many people in the United States hold the view that the society is, in fundamental ways, open. They believe that individuals carve out their life paths by drawing on their personal stores of hard work, effort, and talent. All children are seen as having approximately equal life chances. Or, if children’s life chances appear to differ, this is seen as due to differences in raw talent, initiative, aspirations, and effort. This perspective directly rebuffs the thesis that the social structural location of the family systematically shapes children’s life experiences and life outcomes. Rather, the outcomes individuals achieve over the course of their lifetime are seen as their own responsibility.
There is something naïvely optimistic and quintessentially American (Horatio Algeresque) about this perspective. I can honestly believe that some people hold others personally responsible not out of malice, but because they want this vision to be true. In their limited experience, they feel it was true for them, and therefore it should be true for everyone. Part of the problem here is that most Americans think of themselves as middle class. They resist the idea of social class altogether. (Or, as Christopher Hayes describes so convincingly in Twilight of the Elites: America after Meritocray, the idea that a self-replicating meritocracy produces and perpetuates inequality.) This makes it difficult to acknowledge that a child’s family of origin affects life’s subsequent trajectory.
Lareau’s book describes her research on what it is like to grow up in middle class, working class, and poor US families. It offers a more realistic alternative to the assumption that our childhood circumstances should make no difference in our ability to thrive as adults. Her observations of how children of different social classes learn to interact with authority figures such as medical professionals, for example, are especially revealing.
Based on her research, Lareau concludes:
The social position of one’s family of origin has profound implications for life experiences and life outcomes. But the inequality our system creates and sustains is invisible and thus unrecognized. We would be better off as a country if we could enlarge our truncated vocabulary about the importance of social class. For only then might we begin to acknowledge more systematically the class divisions among us.
Healthy lifestyles undoubtedly make certain individuals healthier. Simply advocating healthy lifestyles for everyone, however, will not create a healthier society. In order for that to work, everyone would need to have control over the conditions that affect their health. Much of what determines health, however, including environmental and occupational risks as well as socioeconomic circumstances, is not under our control. This is true for everyone to some extent, but it is especially true for the poor and socially excluded. Holding individuals responsible for their health is a way to avoid addressing the social and economic issues that produce health disparities. That includes a fundamental reluctance to acknowledge the underlying social dynamics that increase and maintain inequality.
Hope for the future
Are we better off now than we were 18 years ago? After watching highly conservative candidates compete in the Republican presidential primaries this past year, I admit I was tempted to conclude that public opinion on the question of personal responsibility has made no progress since 1994. That would not be accurate, however. Clearly the social determinants of health receive much more attention these days than in the 1990s: the Whitehall Studies, the Commission on Social Determinants of Health, The Spirit Level: Why Greater Equality Makes Societies Stronger, last year’s World Conference on Social Determinants of Health. Unlike 1994, you can enter the hashtag #SDOH on Twitter and link your way to a wealth of information on social determinants of health, generously supplied by enthusiastic advocates. That’s progress.
Marmor et al offered another reason for the disappointing results that followed the new perspective of the Lalonde report: the medical profession. Health care was – and still is — the largest single industry in developed countries. There are bound to be economic and political interests invested in the idea that the only way to confront disease is to deliver (and profit from) more medical care.
There is good news on this front, however. The economic interests are still deeply rooted, and they still present obstacles to change. Doctors in the trenches, however, are very aware that the health of their patients suffers from a failure to meet social needs. A survey conducted last year for the Robert Wood Johnson Foundation found that four out of five US physicians believe it is just as important to address social needs as it is to treat medical conditions.
4 in 5 physicians do not feel confident in their capacity to meet their patients’ social needs, and they believe this impedes their ability to provide quality care. This is health care’s blind side: Within the current health care system, physicians do not have the time or sufficient staff support to address patients’ social needs.
Despite the criticisms of the medical profession in the 1970s, and despite the loss of autonomy US doctors suffered at the hands of HMOs and insurance companies in the 1990s, the medical profession has retained the respect and trust of patients. If 85% of physicians believe unmet social needs are “leading directly to worse health for all Americans,” their voices are a force to be reckoned with.
Looking back, it’s now obvious that the Lalonde report did initiate a change in our fundamental understanding of the determinants of health – an understanding that is now beginning to flourish. By stressing the influence of non-medical factors on population health, the report made it possible for governments, academics, and foundations to endorse practices outside conventional medical care. Medical practitioners are equally aware that health care by itself cannot secure a population’s health.
Following the Lalonde report, politicians, health merchants, and mass media moguls seized on the idea of healthy lifestyles. They tried to convince us that personal responsibility was the primary determinant of health. In the end, however, I am cautiously optimistic that it is not their voices that will prevail.
Why is it so hard to reduce US health care costs?
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
On healthism, the social determinants of health, conformity, & embracing the abnormal: (1) Bodies, minds & medicine
On healthism, the social determinants of health, conformity, & embracing the abnormal: (2) Economics & the socio-political
On healthism, the social determinants of health, conformity, & embracing the abnormal: (3) Connections
On healthism, the social determinants of health, conformity, & embracing the abnormal: (4) The abnormal part
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
Theodore R. Marmor, Morris L. Barer, Robert G. Evans (editors), Why Are Some People Healthy and Others Not?: The Determinants of Health of Populations (1994). See especially chapter 8, ‘The Determinants of a Population’s Health: What Can Be Done to Improve a Democratic Nation’s Health Status?’, by Theodore R. Marmor, Morris L. Barer, and Robert G. Evans.
Annette Lareau, Unequal Childhoods: Class, Race, and Family Life (2011, 2nd edition)