Continued from the previous post, where I discussed the expansion of universal health care prior to the 1970s, how this created a growing demand for health care, and the problem health care costs posed for governments, especially when the economy suffered a downturn in the seventies. One response to the situation was to consider new ideas. Rather than limit strategies to what could be done by the health care industry, why not directly address the underlying causes of disease by considering social determinants of health.
Canada’s Lalonde report
[the] first modern government document in the Western world to acknowledge that our emphasis upon a biomedical health care system is wrong, and that we need to look beyond the traditional health care (sick care) system if we wish to improve the health of the public.
The US Congress emulated this thinking in 1976 by creating the Office of Prevention and Health Promotion. The US Department of Health, Education, and Welfare began publishing the document Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention in 1979. The response in European countries — caught in the same bind of greater demand, increasing costs, and the financial consequences of a deteriorating economic landscape – was similar.
The common thread in these new perspectives on health was the assertion that health could be improved — without increasing health care costs — if we concentrated on such things as the work environment (occupational health), the physical environment (air and water pollution, pesticides and other carcinogens in food), genetics, and healthy lifestyles. The approach was broad: the environment was considered at least as important as the promotion of healthy lifestyles.
That breadth was quickly lost in the response to the new initiatives. The role of lifestyles was “seized upon with a vengeance” (as Marmor et al put it) by politicians, health marketers, and the mass media, each with their own motivations. The situation was made worse when the concept of healthy lifestyles was coupled with the neoliberal assumption that individuals are completely free to “choose” whether they will behave in a healthy or unhealthy manner.
Blaming the individual
The Lalonde report had contained statements such as: “Personal decisions and habits that are bad from a health point of view create self-imposed risks. When those risks result in illness or death, the victim’s lifestyle can be said to have contributed to, or caused, his own illness or death.” It wasn’t such a big leap from assertions like that to blaming the individual.
The willingness to assign blame was right at home in the New Age self-help movement of the 1970s. Here’s an example of self-help advice urging readers to embrace the truth of “You have only yourself to blame if you are unhealthy.”
Different reactions to the same stress factors … are obviously determined by our mental programming. They are a product of how we see the world and how we think we are threatened by it. To me, therefore, it would make far more sense to examine and reverse the negative ways we perceive the world than to spend time and money concocting new pills for the relief of distress. Pills give relief, but they only postpone cure. Cure comes from reversing our perceptions, from discovering how we create our own “realities.” …
We talk about the stress produced by our jobs, our home, our family, our business, the weather, the government, world conditions, and so on. Once again, we are led to believe that we are victims of some outside force that is imposing its will on us and causing us distress. … We choose our own psychological pathogens of stress by the way we choose to perceive and interpret events in our lives.
This is from Inner Balance: The Power of Holistic Healing by Elliott M. Goldwag, published in 1979 (quoted in Crawford). It’s typical of a mindset that was popular in the 1970s (one that survives today in books such as The Secret),
Avoiding the larger issues
By making both the cause of health problems and their solution a matter of individual choice, health promoters avoided issues such as the work environment, the physical environment, the distribution of income, social status, and the financial incentives that drive the health care industry. A typical healthy lifestyle message encouraged individuals to smoke and drink less, eat better, and get more exercise. There was no acknowledgment that individual behaviors occur in and are a result of a social and economic context. And of course there was no suggestion that the context should be changed by taking collective responsibility. Margaret Thatcher went so far as to say there was no such thing as society.
In the workplace, corporations turned the idea of providing a healthy place in which to work into the desirability of a workforce that took responsibility for its health. Companies provided on-site gyms, labeled cafeteria food healthy, and offered drug and alcohol counseling to those brave enough to trust their employer with such personal information. The emphasis continued to be on personal responsibility for health. Unchallenged were the major determinants of health associated with work: income, power, status, lack of autonomy. Self-help books in the seventies offered the advice that if your job was making you unhealthy, it was your responsibility to find a new one.
Promoting individual responsibility for health had two advantages: it avoided challenging existing power structures and it cost virtually nothing. It was both politically and financially cheaper than addressing the circumstances that create unhealthy behavior in the first place.
Healthy lifestyles and the expansion of medical care
Did the new public health measures have any impact on health care costs? Though it hadn’t been the primary goal, it seemed reasonable to assume that healthier people would ultimately reduce costs. Since the healthy lifestyles approach failed to challenge the power structure of the health care industry, however, medicine was free to continue its expansion.
Prevention occasioned a new range of services that the medical profession could offer. Doctors were now paid for anti-smoking counseling. Testing for risk factors (and the pharmaceutical prescriptions that followed) surged. Health was equated with the appearance of health, and surgeons flocked to cosmetic surgery. Alternative practitioners, such as chiropractors and acupuncturists, sought and often won inclusion in health insurance policies.
Individually, no one of these was necessarily a bad thing. Collectively, increased health consciousness was followed by increased health care costs. The promotion of healthy lifestyles was not the only reason health consciousness increased in the late 20th century. And there were, of course, many other forces at work that increased the costs of health care. But it seems fair to say that the new perspective on health ended up providing opportunities to expand the demand for more medical services. Any hope that individual responsibility for healthy lifestyles would reduce costs – still touted today by some politicians and health care economists — turned out to be a mirage.
Continued in the next post, where I discuss how attitudes towards social class influence assumptions about personal responsibility for health, plus some positive signs that the healthy lifestyle mantra may be losing out to a greater appreciation for the social determinants of health.
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
Robert Crawford, Healthism and the medicalization of everyday life, International Journal of Health Services, Vol 10 No 3, 1980, pp 365-388
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