The Health Culture

A culture of health needs a market for health

Jan — Sat, 06 Apr 2013 02:14:37 +0000

This feels encouraging: Two Viewpoint articles in a recent issue of JAMA (The Journal of the American Medical Association) on improving population health (both behind a paywall, unfortunately).

Population health

What is population health? Apparently it depends on who you ask. If you ask those with a financial stake in the health care delivery system, population health means improving the health of patients who currently use (i.e., pay for) the system. You get a different answer if you ask those involved in public health, community development, or social services. They believe “population” should include everyone in the entire geographic community, whether or not those individuals are able to use or benefit from health care services. They also believe “health” should include quality of life and economic well-being – measures that prevent disease in the first place – and not just conditions addressed by the medical model of disease.

What I especially liked about Stephen Shortell’s article – Bridging the Divide between Health and Health Care – was its economic realism. I dearly wish that those with a financial interest in the health care industry, as well as politicians who control health policy, would acknowledge that the way to improve health is to address its social determinants. But trying to change the hearts and minds of stakeholders is like pushing against the tide.

Shortell’s approach appeals to the profit motive. He cites the example of the Cambridge Health Alliance. At this health care system in the Boston area, community health workers reduced childhood asthma, resulting in a return on investment (from fewer hospital admissions and emergency department visits) of $4 for every $1 invested. “To create a culture of health will require creating a market for health, moving away from the current market for treating disease.”

As Orwell warned, choose your language with care

Population health is up for discussion these days because the Affordable Care Act (ACA) – which goes into effect next year — provides $10 billion over 10 years to improve population health (by preventing disease and promoting health, presumably). One mechanism to accomplish this goal is the creation of new funding models such as Accountable Care Organizations (ACOs). ACOs have three goals: to control the cost of health care, to improve the quality of health care, and to improve population health.

As Douglas Noble and Lawrence Casalino point out in their JAMA article — Can Accountable Care Organizations Improve Population Health? Should They Try? — there is only one brief reference to “population” in the entire ACA (906 pages), namely, the Medicare Shared Savings ACO program must promote “accountability for a patient population.” Given this particular context, it would be easy to interpret “population” as those patients enrolled in the ACO, rather than residents in the geographic area the ACO serves.

Noble and Casalino are concerned that a narrow interpretation of population health – improving medical care for a specific group of patients — will divert attention from both public health/social services and the socioeconomic factors that determine health. “It would be unfortunate if ACOs, which have been conceived in idealistic terms, were to result in a narrowing and medicalization of the phrase ‘population health.’”

The authors mention possible incentives that might motivate ACOs to address population health in the broad sense of that term. Their main concern in this article, however, is their fear that the very meaning of the term will be lost.

From personal responsibility to population health

Despite the causes for concern raised by these authors, I find that the mere publication of their viewpoints in JAMA is encouraging. It was not that long ago (2010) that a highly respected health care expert, Robert H. Brook, wrote in a JAMA commentary: “Should [health] insurance be more costly, or even withdrawn, not because individuals become sick but because they do not use preventive services or evidence-based care in a manner that both protects their health and reduces health care costs for others. … [W]hat kind of penalty for misuse would be ethically and morally acceptable?”

In a subsequent exchange of letters to the editor, Brook displayed – more or less successfully — his history of appreciating the importance of the social determinants of health. He proposed, for example, that penalizing only the middle and upper classes might save money that could then be used to “change the environment and reduce the effect of social determinants for everyone.”

I’m hoping that what I sense in 2013 is a change in attitude towards population health among medical professionals. Shortell concludes his article:

Like a hologram in which the whole is embedded in each part, health care delivery is embedded into population health and population health is embedded into health care delivery. It is now the responsibility of clinicians and health care delivery organizations to help maintain the health of the community and the responsibility of the community to help maintain the health of the individual.

May the dialogue continue.

References:

Douglas J. Noble, MD, MPH and Lawrence P. Casalino, MD, PhD, Can Accountable Care Organizations Improve Population Health? Should They Try?, JAMA, March 20, 2013, Vol 309, No. 11

Stephen M. Shortell, PhD, MPH, MBA, Bridging the Divide between Health and Health Care, JAMA, March 20, 2013, Vol 309, No. 11

Robert H. Brook, MD, ScD, Rights and Responsibilities in Health Care: Striking a Balance, JAMA, June 9, 2010, Vol 202, No 22

Robert H. Brook, MD, ScD, Balancing Responsibilities in Health Care—Reply, JAMA, September 15, 2010, Vol 304, No 11

For one explanation of the term population health, see this Wikipedia entry

Healthy lifestyles: Social class. A precarious optimism

Jan — Mon, 08 Oct 2012 21:22:57 +0000

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.

References:

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)

Healthy lifestyles: The unfortunate consequences

Jan — Mon, 08 Oct 2012 20:48:40 +0000

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

In 1974, Canada produced the Lalonde report. It has been described as

[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.

References:

A New Perspective on the Health of Canadians (Lalonde Report) (1973-1974)

Robert Crawford, Healthism and the medicalization of everyday life, International Journal of Health Services, Vol 10 No 3, 1980, pp 365-388

Healthy lifestyles: The antecedents

Jan — Mon, 08 Oct 2012 01:02:59 +0000

In the 1970s, public health policies began to promote the idea that individuals are responsible for their health and therefore have an obligation to adopt healthy lifestyles. Over the ensuing decades, health became both an extremely popular topic for media coverage and a lucrative market for vendors of health-related products and services. What followed was a substantial increase in health consciousness and greater anxiety about all things that concern the body.

Do healthy lifestyles actually produce better health? That they should may seem like common sense, which is one reason it’s been so easy to promote the idea that they do. The question is difficult to answer with absolute certainty, however. For one thing, the behavior that counts towards a healthy lifestyle does not readily lend itself to the objective measurements required for reliable scientific evidence. Defining health is also tricky. Lifespan is often used to compare the ‘health’ of different nations, but this fails to capture the subjective sense of health that is meaningful to individuals. Perhaps most important, while in theory a healthy lifestyle might improve health, that does little good if – as is now obvious – it’s extremely difficult to maintain behaviors that require things like changing what we eat and how often we exercise.

A related question would be: Did the promotion of healthy lifestyles reduce health care costs? This too seems like a sensible assumption, and the assertion is quite popular, especially among politicians. Health care costs have increased to hand-wringing levels. Promoting healthy lifestyles costs governments next to nothing, while the cost of health care is all too easily quantified.

A review (by the Centers for Disease Control) of over 3,200 scientific articles on the health effectiveness and cost-effectiveness of disease prevention found only five examples where prevention led to cost savings (this was in 1993). They were all in the area of immunization and prenatal care. This counts as prevention, certainly, but it’s not the diet/exercise/smoking advice we typically think of when we hear the words ‘healthy lifestyle.’ Given prevailing health trends over the last few decades, it’s now apparent that the extensive promotion of healthy lifestyles has done little to prevent the expensive health consequences of such things as excessive weight gain and diabetes.

Other opinions on the question of cost effectiveness (admittedly not backed by scientific evidence) include those of Dr. Arthur J. Barsky and Robert Crawford. Barsky argues that the more we pay attention to the body (a natural consequence of increased health consciousness) the more likely we are to identify symptoms we regard as unhealthy. This in turn leads us to seek more medical care. So healthy lifestyles may make us feel less healthy, and for this we pay more.

Cultural historian Crawford contends that the promotion of individual responsibility — for health, in particular, but for other aspects of our lives as well — allowed neoliberals to privatize all too many aspects of our economy. Now that we’ve suffered the consequences of neoliberalism, we know that it increases both inequality and costs. Inequality decreases population health, and the increased costs of privatization include the costs of health care. An appreciation of the adverse consequences of privatization motivated opponents of the Health and Social Care Act 2012 in Great Britain.

Healthy lifestyles: Why now?

Although the desire to maintain health and recover from illness is certainly nothing new historically, there was something distinctly different about the promotion of healthy lifestyles starting in the 1970s. Why did this happen when it did?

The 1970s saw greatly increased concern about the costs of health care. In response, a new perspective on health appeared, as seen in policy documents such as the Canadian Lalonde report. What was new about this perspective was the idea that health policy should address issues outside the scope of the health care industry, including determinants of health such as the physical environment and the workplace. Health care had become nearly universal and yet it was still inadequate to address health needs, especially chronic conditions. It had also failed to address health inequalities. The new goal was to find better ways to improve health.

If this new perspective had been implemented as it was originally intended in the Lalonde report, there might very well have been improvements in population health. When economic and political interests chose to limit their support to the promotion of healthy lifestyles, an opportunity was lost.

In this post and the next I discuss some of the historical background that led up to the Lalonde report and the subsequent promotion of healthy lifestyles. For both information and insight, I am indebted to the book Why Are Some People Healthy and Others Not? When this book was published in 1994, the authors were disappointed that the new perspective had little impact on improving health. In a third post, I suggest that there are reasons to be more optimistic today.

The goal of universal health care

During the decades from 1920 to 1970, sickness insurance became increasingly available in industrialized democracies. There were several reasons for this. Some people, of course, believed it was the right thing to do. That was not the primary motivation, however. Wars, such as WW I, had a way of making governments aware of how desirable it was to have healthy young men.

There was also a widespread, optimistic belief that scientific medicine would change the incidence and treatment of common diseases. Even before sulfa drugs and penicillin produced dramatic results for infectious diseases, there had been considerable success in reducing infant and child mortality. This was most likely due to improved hygiene, not advancements in medicine. That wasn’t perfectly clear at the time, however, and public esteem for the medical profession increased.

WW II was yet another opportunity for governments to reflect on the health of citizens. The war also provided a huge dose of experience for young doctors practicing battlefield medicine. After the war, the shared experience of having fought and defeated an enemy contributed to the sense of community that made welfare programs possible. In Britain, plans for universal coverage had already begun to take shape in 1941.

Prior to the 1970s, increased spending on access to health care was considered social progress. (This was true even in the United States, which is now the only advanced country that still does not have universal health care.) Concerns about costs were offset by the widespread optimism that medical care would provide great benefits. The expansion of medicine was encouraged and welcomed. This benevolent attitude ended abruptly with the economic reversals of the 1970s (the oil crisis, unemployment, inflation).

The need to control costs

In the 1970s, government priorities changed from the desire to make health care more accessible to the need to control its escalating costs. It turned out to be much harder to contract the growth of health care than it had been to expand it. The medical industry seemed quite capable of expanding indefinitely, and it continued to do so.

As health care consumed a larger percentage of what governments were willing to spend, there was less money available for other public goods that influence the health and well being of a nation: safer roads, a cleaner environment, education, even an adequate police force. This was a serious problem.

It was the expansion of health care availability that had created a growing demand for more health care in the first place. This demand was not going to go away. (Promising less is never a popular political position.) Those who sought to restrain health care costs were up against popular new health care systems (Britain’s NHS, Canada’s provincially based medicare system, Medicare in the US). These opposing forces – a growing demand and the need to control costs – created a conflict, a dynamic that continues to this day.

A willingness to consider something new

By the 1970s it was apparent that the attempt to provide universal access had not eliminated health inequalities and inadequacies, but there was also something else going on — a decline in the medical profession’s public esteem. In part, this was related to disappointment in medicine’s progress: it proved much more difficult to prevent or cure chronic diseases than to eliminate infectious ones. But the decline was also part of a critical attitude towards a profession now seen as too powerful. According to some critics, the doctor (white/male) saw himself as God, and medicine had taken on a moral role previously reserved for religion.

The less optimistic attitude towards medicine’s future, the failure of increased health care access to make everyone healthy, and hostile criticism of a powerful medical profession created a climate in which new ideas — outside-the-box thinking – were welcomed, at least in some quarters. If medical science was not going to cure cancer, prevent heart attacks, or reduce the incidence of diabetes any time soon, what else might help? Were there things that could be done outside the sphere of costly biomedicine that would enhance health?

There were obstacles to pursuing a new path. The demand for more health care in a time of spiraling costs had a way of directing all attention and policy funding towards the health care system itself. There were few resources available to develop health improvement programs outside the medical paradigm. And within the medical profession, there was little financial motivation (and thus little enthusiasm) for programs that were not already part of conventional medical care.

Despite the obstacles, some governments were willing to give new ideas a try. In particular, Canada produced a major health policy document: the innovative and influential Lalonde report.

Continued in the next post, where I discuss the Lalonde report and what followed the introduction of these new ideas.

References:

Callahan, Daniel, Promoting Healthy Behavior: How Much Freedom? Whose Responsibility? (2001)

A more equitable future? US reveals its true intentions

Jan — Tue, 25 Sep 2012 00:42:59 +0000

Why is it so hard to convince policy makers worldwide to address the social determinants of health, including poverty, hunger, and income inequality? Judging by the excerpt below, we shouldn’t count on the US to champion this cause any time soon. It’s from a document called “The Future We Want,” issued by the Rio+20 conference last June. The US requested changes to the document, indicated in bold (additions) and strike-outs (deletions).

Eradicating poverty is the greatest global challenge facing the world today and an indispensable requirement for sustainable development. In this regard we are committed to free humanity from extreme poverty and hunger as a matter of urgency.

We recognize that promoting ~~universal~~ access to social services can make an important contribution to consolidating and achieving development gains.

We strongly encourage initiatives ~~at all levels~~ aimed at ~~providing~~ enhancing social protection for all people.

We ~~appeal to~~ invite all States, relevant international organizations, the private sector, and all major groups to enhance their efforts to achieve sustainable changes in consumption and production patterns while creating new economic opportunities and decent work, and ~~securing good~~ enhancing living standards ~~and protection of vulnerable groups~~.

We reaffirm the urgent need to deepen the reform of the global financial system and architecture based on the principles of equity, sovereign equality, independence, common interest, cooperation and solidarity among all States.

~~We urge developed countries to undertake significant changes in the lifestyles of their people to move towards a more sustainable future for all.~~

Heaven forbid we should ask Americans to make changes to their lifestyles. Why, that’s almost as bad as believing in redistribution.

I found this excerpt at Harpers (behind a paywall), where it was cleverly titled “Brazil Nots.”

Profit-driven medicine: Satisfying patients at the expense of their health

Jan — Mon, 30 Jul 2012 00:55:17 +0000

Patient Satisfaction & Patient-Centered Care: Necessary but Not Equal bit.ly/MN7Yan JAMA Highly satisfied patients had worse outcomes

— Jan Henderson (@HealthCulture) July 26, 2012

Why would patients who report greater satisfaction with their health care be worse off medically? This JAMA article, Patient Satisfaction & Patient-Centered Care: Necessary but Not Equal, offers an explanation that makes sense. It points to the commercialization of health care – treating the patient as a consumer – as the villain. (All quotations in what follows are from this article.)

The patient (consumer) satisfaction survey

In the US, many doctors are evaluated and rewarded based on patient satisfaction surveys. Motivated to produce high patient satisfaction scores, doctors are inclined to order more diagnostic tests. Why? It’s more than a simple desire to please the patient.

When physicians’ performance evaluations and incomes are tied to patient satisfaction, the situation becomes ripe for overuse and misuse of diagnostic and therapeutic procedures because it allows the physician to rationalize decision making in terms of patient satisfaction.

Pleasing a patient is a conscious, individualized choice. Rationalized decision making can easily become an automatic habit that requires no additional thought.

In addition to overuse of diagnostic tests, doctors are also accused of overprescribing many categories of drugs (antibiotics, statins, pain killers, antidepressants). Patients in turn are blamed for expecting an office visit to result in a prescription. When patients are free to change doctors, and doctors in private practice depend on patients for their income, satisfying patients appears as logical as the desire for economic survival.

Here’s where the harm comes in: Patients who receive more diagnostic tests are more likely to be overdiagnosed, leading to unnecessary and possibly harmful procedures. Patients who take more drugs are more likely to suffer the potentially harmful side-effects that accompany any pharmaceutical product. So the patient is highly satisfied, but worse off.

[H]ighly satisfied patients had higher health care use and worse outcomes, even though they rated their own health as excellent.

Medicine as a profit-driven business

I was pleased to see that this article, in The Journal of the American Medical Association no less, addressed the commercialization of health care. The article comes right out and says that using patient satisfaction as “perhaps the most desirable medical outcome” (emphasis added) originates in consumer marketing. Hospitals and HMOs are especially dedicated to the value of patient satisfaction. The companies that create and supply patient satisfaction surveys maintain there is a ”significant association” between higher satisfaction and fewer malpractice claims. They even suggest that satisfied patients may benefit medically from the placebo effect.

Dr. Arnold Relman, a former editor of The New England Journal of Medicine and originator of the term ‘medical-industrial complex,’ is one of those who argues that medicine was never intended to become a profit-driven business. There are significant differences between consumers of ordinary goods and services and patients seeking medical care. I list a number of the more obvious differences here. The JAMA article mentions two that relate directly to patient satisfaction.

One, it is difficult for patients to evaluate the quality of their care. For example, patients may overemphasize the value of physician behavior that can be objectively measured (the number of tests ordered), but dismiss and not value more subjective behavior (advice to stop smoking or lose weight). There is an asymmetry of knowledge – a patient can’t possibly be as informed as a doctor about what’s wrong and what’s needed.

Two, unlike most business transactions, the majority of patients do not pay directly for the services they receive. Payments happen through a third party, most commonly in the US through an insurance company. In a business transaction, the consumer experiences an immediate and direct trade-off between the cost and the quality of the service rendered. If you pay more, you expect more. This expectation acts as a control mechanism on costs. In medicine, this trade-off is absent. The result: “neither patients nor payers make decisions with a holistic view of the trade-offs involved,” where holistic includes both the best interests of the patient and the financial viability of health care.

From a business perspective, greater customer satisfaction should improve profits.

Corporate interest in customer satisfaction has focused on improving corporate profits through the satisfaction-profit chain by creating customer retention, loyalty, and repeat business.

Corporatized, profit-driven medicine can achieve all three of these goals. Patients are not well-served, however, when the commercialized, privatized business model is applied to health care. The result is superficially satisfied patients who make greater use of the health care system at the expense of their own health.

References:

John M. Kupfer, Edward U. Bond, Patient Satisfaction & Patient-Centered Care: Necessary but Not Equal, JAMA, July 11, 2012, Vol 308, No 2, pp 139-140

Melvin F. Hall, Looking to Improve Financial Results? Start by Listening to Patients, Healthcare Financial Management Association

Arnold Relman, A Second Opinion: Rescuing America’s Health Care (2007)

On healthism, the social determinants of health, conformity, & embracing the abnormal: (4) The abnormal part

Jan — Fri, 20 Jul 2012 21:34:16 +0000

Continued from parts one, two, and three.

A year ago, when I decided to call my declining rate of blogging a ‘sabbatical,’ I wrote down some questions to explore while I took time off to read.

How did we find our way into the dissatisfactions of the present – the commercialization of medicine, the corporatization of health care, the commodification of health? Does understanding the path we followed offer any insight into finding a better direction? Was the increasingly impersonal nature of the doctor-patient relationship inevitable once medicine became a science? Or was it only inevitable once health care emphasized profits over patients and the common good?

At the time I thought I would read primarily in the history of medicine, and that was how I started. Appreciating the historical context of medicine is important for understanding both how medicine ended up where it is today and what medicine could become. “The texture and context of the medical past provide perspective, allowing us to formulate questions about what we can realistically and ideally expect from medicine in our own time,” I wrote.

Now that I’ve become more familiar with the social determinants of health, I’m less optimistic about the future. The problem is not simply that the corporatization of health care has increased dissatisfaction among both doctors and patients. The problem is that our focus is so narrowly limited to health care systems that we fail to see the larger issue. As one metaphor puts it, doctors are so busy pulling diseased patients out of the river, there’s no time to look upstream and ask who’s throwing the bodies into the water.

Looking for clues in the questions we fail to ask

One of the books I read this past year was Our Present Complaint: American Medicine, Then and Now, by medical historian Charles Rosenberg. I was very struck by his comments on the ‘invisibility of contingency.’ (This is just a fancy way of saying that we assume our present situation must have been inevitable and don’t stop to acknowledge the arbitrariness — and thus malleability — of the way things are.) I referred to this in a post on healthism:

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.

Healthism was what started me blogging in 2008. It seemed like a clue to something I wanted to understand. What I realize now is that the clue I discovered in healthism is yet one more thing that unites my interests, as I’ll try to explain below.

Embracing the abnormal

The six categories I’ve discussed in these posts are not simply a collection of abstract intellectual interests. They have a strong personal resonance for me. That’s probably why I was so reluctant last year to limit myself to any one topic.

My interest in the social determinants of health may stem from my slightly unusual family of origin. It combined elements of both the working and middle classes (father an uneducated factory worker, mother a stay-at-home college-educated library user). Something about this confused me as a child, and I ended up feeling different. Thanks to wonderful high school teachers, scholarships, and an era of generous financial aid from the federal government, I was able to attend elite post-secondary schools. My family and my class-conscious educational environment may account for my interest in social disparities.

Feeling different, it’s perhaps not surprising that I developed an interest in deviance, conformity, and what it means to be ‘normal.’ I was fortunate to come across a set of ideas — the sociology of knowledge — that allowed me to embrace the abnormal (see my post The problem is you).

I referred to those ideas in one of my first posts:

I was struck by the concepts of the taken-for-granted nature of the world, the stock of knowledge we inherit, the limitations imposed on our conceptions and even our perceptions by the very language we speak, as well as by the time and culture into which we’re born. These ideas resonated with me at a very deep level. They seemed to offer a means to wake up and escape from the unquestioned dream of life.

Waking up includes the recognition that what’s ‘normal’ changes over time and serves economic, political, professional, and/or cultural (as in ‘culture war’) interests.

When Charles Rosenberg refers to the invisibility of contingency, he’s talking about the taken-for-granted nature of the world. When we are told that people who are overweight or who suffer from poor health have only themselves to blame because their lifestyles have been insufficiently healthy, that reasoning is superficial. If we look deeper we discover multiple motivations for the ‘personal responsibility’ message that have nothing to do with lifestyles. We don’t suspect those motivations if we take it for granted that the ‘healthy lifestyles’ mantra is the only explanation we need to account for the inequitable distribution of disease and mortality.

I was initially attracted to the subject of healthism because I felt I’d been taken in by health messaging. But I also suspected there was something worth waking up to here. I now see that what lies beneath the taken-for-granted – the questions that don’t get asked in media coverage of health issues or in the health policies of governments — unites my blogging topics and makes them personally meaningful.

In whose interest is neoliberalism? Medicalization? Conformity? Non-holistic medicine? The commercialization of health? Healthism? More often than not the answer is that none of these are in my interest. Nor are they in the interests of a society I would want to live in. When an entrenched system of medical care has a vested interest in maintaining an understanding of health that preserves the status quo, and when that status quo is no longer in our collective interest, it becomes necessary and important to challenge the new normal.

I’d like to thank all the interesting and helpful people I’ve met on Twitter during my year of being on ‘sabbatical.’ They have broadened and sustained my interests and deepened my understanding in so many ways. Twitter turned out to be a wonderful place to indulge all those interests I haven’t even mentioned here. I’d especially like to thank Dr. Jonathan Tomlinson, who writes movingly about the plight of patients in a neoliberal world, and Pierre Fraser, whose writings on health as a social value and the export of American individualism have influenced my thinking. Finally, I am deeply grateful to Deborah Lupton, Carl Elliott, and Robert Crawford for everything they have ever written.

References:

Charles Rosenberg, Our Present Complaint: American Medicine, Then and Now (2007)

Peter L. Berger and Thomas Luckmann, The Social Construction of Reality: A Treatise in the Sociology of Knowledge (1967)

Deborah Lupton, The Imperative of Health: Public Health and the Regulated Body (1995)

Carl Elliott, Better Than Well: American Medicine Meets the American Dream (2004)

Robert Crawford, Healthism and the medicalization of everyday life, International Journal of Health Services, 1980, 10(3), pp 365-88

On healthism, the social determinants of health, conformity, & embracing the abnormal: (3) Connections

Jan — Thu, 19 Jul 2012 06:14:21 +0000

Continued from parts one and two, where I defined the terms used in the following diagram of my blogging interests. Click on the graphic for a larger image.

If I had written the previous two posts a year ago, I would have realized how much my interests were intertwined. I guess I wasn’t ready to do that. Anyway, in this post I catalog some of the connections.

Healthism

~ Healthism and psychological and physical conformity: Healthy lifestyle campaigns promote an ideal way of life that encourages individuals to alter their behavior and appearance. Although it’s true that we would all be better off if we didn’t smoke, that doesn’t make anti-smoking laws any less authoritarian, i.e., requiring conformity (see the section on anti-authority healthism in this post). The fitness aspect of healthy lifestyles promotes the desirability for both men and women of acquiring (i.e., conforming to) specific body images.

“Self-help is the psychiatric equivalent of healthism.” That’s a slogan I made up. I’m not sure yet if it will stand up to scrutiny. Certainly the self-help industry encourages self-criticism, which leads to a preoccupation with those aspects of personality currently considered undesirable.

~ Healthism and medicalization: Once a bodily process or characteristic has been labeled a medical condition, the ensuing publicity (advertisements, news stories) encourage us to be concerned (anxiety healthism). This increases our willingness to seek and agree to medical treatment, which can lead to overdiagnosis.

Direct-to-consumer (DTC) ads for pharmaceuticals increase our anxiety about previously normal behaviors and diseases we do not (yet) have, increasing both healthism and overdiagnosis. Disease mongering only works if it can generate anxiety healthism. The promotion of personal responsibility for healthy lifestyles encourages us to seek medical attention even in the absence of symptoms. This also contributes to overdiagnosis.

~ Healthism and corporatism: The sale of health goods and services, especially under the guise of healthy lifestyles, is highly profitable. Since it’s easy to create anxiety about health and often quite difficult for people to change their health behaviors, this is a market with seemingly infinite potential (featured in book’s like The Wellness Revolution: How to Make a Fortune in the Next Trillion Dollar Industry). Once health and health care are controlled by financial interests, there is strong motivation to increase consumption, hold individuals responsible for healthy lifestyles, and encourage healthism.

~ Healthism and neoliberalism: Healthism, healthy lifestyles, and personal responsibility for health focus attention on the individual. This obscures and distracts from the social conditions that contribute to disease. This strategy is a core tenet of neoliberalism. “[I]ndividual responsibility as ideology has often functioned historically as a substitute for collective political commitments.” (Crawford)

~ Healthism and social determinants of health: Health policies that emphasize healthy lifestyles and personal responsibility for health are based on the assumption that health and disease are under the individual’s control. This works against a broader understanding of the role of social determinants of health. “Individualism … looks to change individual behavior, not the conditions that give rise to inequalities.” (Hofrichter)

Psychological and physical conformity

~ Conformity and medicalization: Medicalization is a prime mechanism for promoting psychological and physical conformity. Can you say ‘deviance’? Are you ‘at risk’?

~ Conformity and corporatism: Surgically altering one’s appearance (e.g., designer feet) presumably increases one’s chance of success in a society that commodifies bodies (i.e., in a society where salary, career advancement, social status and marriage prospects are influenced by appearance). Altering one’s personality with psychopharmaceuticals allows one to project the qualities necessary for success in a highly competitive society.

Another slogan: “Cosmetic surgery is the physical equivalent of ‘better than well’ psychopharmaceuticals.”

~ Conformity and neoliberalism: Although neoliberalism emphasizes the ideology of the individual, it does not advocate broadening the definition of normal. Economies work best when individuals conform to the dominant ideals of society. Increasingly this conformity can be aided by medical intervention (psychopharmaceuticals, cosmetic surgery, weight loss surgery).

Another connection, pointed out by Barbara Ehrenreich: Positive thinking promoted by self-help gurus is a useful way to blame the individual for “the crueler aspects of the market economy.”

~ Conformity and social determinants of health: Medical efforts that help the individual conform to cultural norms – both psychological and physical — involve identifying and altering characteristics that are unique to the individual. Whether it’s the neurochemistry of an individual’s brain or the modification of a body part, these efforts are examples of reductionism and the medical model. The focus on the individual ignores and leaves unquestioned the social environment that establishes the norms. Rather than ask how the environment (social, economic, physical) could become more conducive to health, medical intervention allows individuals to accommodate themselves (conform) to the existing environment.

Medicalization

~ Medicalization and corporatism: One of the drivers of overdiagnosis is the desire to increase revenue (e.g., physician remuneration based on pay-for-service, where services typically include screenings that lead to overdiagnosis).

As I discussed in part one, the pharmaceutical industry increases profits by engaging in disease mongering. Patient populations are expanded by redefining a condition (ED) or lowering cut-off points (diabetes, high blood pressure, osteoporosis, high cholesterol level).

~ Medicalization and social determinants of health: Many examples of medicalization (e.g., lowering cut-off points) emphasize individual risk and risk prevention — a feature of the medical model. The primacy of the medical model in health policy decisions means that modifications of existing health care systems receive much greater consideration than social determinants of health.

Corporatism

~ Corporatism and neoliberalism: Neoliberal policies – free trade, deregulation, supply-side economics – favor corporate interests over the public good.

Mitt Romney’s business career exemplifies the influence of neoliberalism on corporations. His consulting firm, Bain Capital, was influential in the evolution of corporate values from a broad set of responsibilities to an exclusive focus on share-holder profits. (See an excellent article on this here.)

~ Corporatism and social determinants of health: Corporate interests emphasize short-term profits at the expense of public health. They also create externalities (side-effects such as environmental pollution) that often affect the economically disadvantaged disproportionately.

Neoliberalism

~ Neoliberalism and social determinants of health: Neoliberalism seeks to eliminate government policies that promote greater equality (especially welfare policies). This exacerbates health inequities. Greater inequality in turn undermines the social infrastructure, which contributes to a loss of social cohesion. (Coburn (PDF)) A society that does not value the public good will not advocate policies that reduce social and economic inequality.

Looking backwards

While writing this post I wondered why I had failed to see all along how interconnected my ideas were. Just as I was finishing, though, I came across a reassuring thought. It was in an essay by a medical student, reflecting on her learning process: “[T]he only stable truth is that which one has struggled for, even if it is something, looking back, we feel we could have known from the beginning.”

Whew! Continued in one final post, part 4, where I look back on my year off, explain why these topics are not simply intellectual interests but are personally meaningful to me, and explain “embracing the abnormal.”

References:

Paul Zane Pilzer, The Wellness Revolution: How to Make a Fortune in the Next Trillion Dollar Industry (2002)

Robert Crawford, Healthism and the medicalization of everyday life, International Journal of Health Services, 1980, 10(3), pp 365-88

Richard Hofrichter (editor), Health and Social Justice: Politics, Ideology, and Inequity in the Distribution of Disease (2003)

Trisse Loxley, Designer feet: Women who will do anything to fit into their Jimmy Choos, Elle Canada

Barbara Ehrenreich, Bright-sided: How the Relentless Promotion of Positive Thinking Has Undermined America (2009)

Benjamin Wallace-Wells, The Romney Economy, New York Magazine, October 23, 2011

David Coburn, Income Inequality, Social Cohesion, and the Health Status of Populations: The Role of Neo-liberalism (PDF), Social Science & Medicine (2000), 51, pp 135-146

Caleb Pressman Gardner, A Moment’s Thought: How to Tell a True Medical Story, JAMA, June 13, 2012

On healthism, the social determinants of health, conformity, & embracing the abnormal: (2) Economics & the socio-political

Jan — Wed, 18 Jul 2012 06:02:50 +0000

Continued from part one, where I discussed the first three of my six interests: healthism, medicalization, and psychological and physical conformity. Click on the graphic below to see a larger image.

The social determinants of health

Social determinants of health (often abbreviated SDOH) refers to unequally distributed social and economic conditions that correlate with unequal and inequitable distributions of health and disease. Presumably there is a causal relationship between the two, not merely a correlation. Definitively identifying the causal mechanisms, however, is difficult. A great many things influence our health (including things we’re not even aware of yet), and it can be difficult to isolate and scientifically study some of the ones we strongly suspect, like poverty, isolation, or a sense of being socially inferior.

The medical model is the preferred framework in modern westernized societies for explaining the distribution of health and disease. It emphasizes risk behavior (smoking, diet), clinical risk factors (blood pressure, blood sugar, cholesterol levels), genetics, health care access and quality, behavioral change, and patient education. One common characteristic of the medical model’s explanation of health and disease is that causes are located in the individual (behavior, genes), not in the individual’s economic and social environment.

In psychiatry, the medical model refers to the assumption that ‘abnormal’ behavior is the result of a physical problem (physiological, biochemical, and/or genetic) and should be treated with a medical intervention such as pharmaceutical drugs.

Reductionist vs. holistic medicine refers to the way the medical profession considers and treats patients. Modern scientific medicine is reductionist in that it understands disease by analyzing increasingly more minute biological entities (cells, molecular interactions, DNA). Reductionist medicine confines its interests not only to isolated individuals, but to isolated parts of the body (as in medical specialties).

Holistic medicine considers individuals in their environments. It was common until the late 19th century, and there was an unsuccessful attempt to revive holism in the 1930s. Much of the appeal of alternative health practices today is their holistic approach to the individual.

In a society that places a high value and financial priority on the medical model and reductionist medicine, it is difficult to implement policies that acknowledge the social determinants of health.

Neoliberalism

Neoliberalism refers to a set of economic assumptions: government policies should favor the wealthy since wealth will “trickle down” (supply-side economics); markets work best when there is no interference from government (free trade, deregulation); public services (education, health care, utilities) operate most efficiently (and profitably) when run as private businesses. Neoliberalism gives priority to the ideology of the individual at the expense of social welfare policies (e.g., Thatcher’s famous “There is no such thing as society”).

Neoliberalism is associated with the economic theory of Milton Friedman and the political policies of Margaret Thatcher and Ronald Reagan. The shift to neoliberal policies that began in the 1970s and 1980s has had a significant impact on health, social welfare, and the medical profession. The recent battle by health care professionals in the UK against government mandated privatization of the National Health Service (NHS) was an attempt to resist the application of neoliberal policies to health care (see Jonathan Tomlinson on A better NHS).

The corporatization of medicine

I think of this topic as having three stages that blend into each other. The commodification of health encourages the public to view health goods and services as just another commodity (the patient as consumer). The commercialization of health is the recognition by business interests of just how profitable the health field can be. The corporatization of medicine is simply a more advanced stage of commercialization, where businesses compete with each other, consolidate into corporate entities, and concentrate on profits in order to maximize returns to shareholders.

The fallacy in this whole arrangement – a fallacy that makes commercialized and corporatized medicine highly detrimental to the physical, mental, and financial well being of the public — is that health is profoundly different from commodities that are typically bought and sold in a market economy (see From MD to MBA: The business of primary care). For more on the disastrous consequences of corporatized medicine in the US, see Maggie Mahar’s excellent book Money-Driven Medicine. For a discussion of the situation in the UK, see Tomlinson on Patients not Profits. How Markets dehumanise health.

I single out the pharmaceutical industry for inclusion in this category for several reasons: its corporate nature (shareholder profits take precedence over the health and safety of consumers); its direct sales appeal to consumers (DTC advertising in the US); and its enormous influence on the very nature of the science of medicine (on this see Corporate Science and the Husbandry of Scientific and Medical Knowledge by the Pharmaceutical Industry (PDF)).

Continued in part three, where I enumerate the (now obvious, I presume) connections that unite what I once saw as a collection of unrelated parts.

References:

Jonathan Tomlinson, A better NHS, Abetternhs’s Blog, July 19, 2011

Sara Henderson and Alan Petersen (editors), Consuming Health: The Commodification of Health Care (2001)

Maggie Mahar, Money-Driven Medicine: The Real Reason Health Care Costs So Much (2006)

Jonathan Tomlinson, Patients not Profits. How Markets dehumanise health., Abetternhs’s Blog

Alastair Matheson, Corporate Science and the Husbandry of Scientific and Medical Knowledge by the Pharmaceutical Industry (PDF), Biosocieties (2008), 3, pp 355–382

On healthism, the social determinants of health, conformity, & embracing the abnormal: (1) Bodies, minds & medicine

Jan — Tue, 17 Jul 2012 03:58:14 +0000

It’s always hard to be sure about these things, but I think the reason I decided to take a ‘sabbatical’ from blogging last July was that I was interested in too many seemingly unrelated topics. Writing about all of them left me feeling like I never got to the ‘meat’ of any one of them. And I couldn’t convince myself to focus on just one or two things, since that would mean abandoning the others, which I was unwilling to do.

Now that I’ve taken the past year to read and reflect, I find – duh! – that my interests are not as unrelated as I’d assumed. In hindsight, I should have realized this long ago, but, alas, I did not. I’m writing this post to clarify to myself what I now see as the common threads that connect my interests.

Here is a diagram that groups my interests into six categories. (Click on the graphic to see a larger image.)

Four of the six categories relate to all five of the others. The two outliers (neoliberalism and medicalization) are not as directly related as I feel the others are.

This post ended up being so long that I’ve divided it into four parts. The first two contain definitions, part three spells out the connections, and part four explains why these topics are especially meaningful to me.

Healthism

Healthism (excessive, usually anxious preoccupation with health) frequently motivates healthy lifestyles (diet, exercise, not smoking, etc.). Failure to observe healthy lifestyles has been used (medically and politically) to blame individuals who are ‘insufficiently’ responsible for their health (personal responsibility for health).

Medicalization

When a normal bodily process/characteristic (menopause, height) or a previously normal behavior (sadness, shyness) is no longer considered normal but something worthy of medical diagnosis and treatment, that’s medicalization.

Disease mongering often coincides with medicalization. When a pharmaceutical company generates anxiety about a benign condition (for which it just happens to sell a product), that’s disease mongering. Listerine was a relatively unsuccessful product for dandruff until Warner-Lambert increased awareness of something that sounds like a serious medical condition: halitosis. The process of turning heartburn into gastroesophageal reflux disease (better known as GERD) illustrates both medicalization and disease mongering.

Another variation on disease mongering is to suggest to the well that they may unknowingly suffer from an existing disease. “Do you know your number?” (for cholesterol) campaigns are an example. Another one: Direct-to-consumer cardiac screening and whole body scans.

Overdiagnosis is a less disparaging, more medically acceptable term for how seemingly healthy people can acquire a disease label overnight. When the cut-off point for diagnosis of a disease (high blood pressure, diabetes) is lowered, millions of people transition from healthy to sick. This often happens when a new drug becomes available.

Of course the authors of an updated clinical guideline that accomplishes such a transition would not call this overdiagnosis. They would say that people who believed they were healthy were — with the wisdom of hindsight — actually sick. The assessment of disease by the use of surrogate markers (cholesterol level, blood sugar level) rather than endpoints (morbidity, mortality) leaves a large gray area into which overdiagnosis creeps.

Overdiagnosis also happens, innocently enough, as a side-effect of modern imaging technology. A diagnostic screening that seeks to explain symptoms in the lungs may reveal incidentalomas (tiny, asymptomatic tumors that would never amount to anything) in near-by parts of the body. This can lead to unnecessary and even harmful treatment.

Overdiagnosis of mental health conditions has produced epidemics of depression, social anxiety, and childhood disorders. This phenomenon has been especially pronounced since the 1980 revision of the American Psychiatric Association’s reference work, the Diagnostic and Statistical Manual of Mental Disorders (DSM-III).

It’s easy and common to blame financial and professional interests for the prevalence of medicalization, disease mongering, and overdiagnosis, but surely this could not have happened without a susceptible and receptive public. Some aspects of healthism may explain our willingness to regard the risk of disease as sufficient reason to medicate our surrogate markers. As for the enormous increase in psychiatric disorders, significant social changes have undoubtedly altered the individual’s self-perception (see Is the prevalence of depression related to the modern empowerment of the individual?).

Psychological & physical conformity

This category may seem a bit of a grab bag at first. What unites its contents is the use of medicine and psychiatry to ‘help’ individuals conform to social pressures.

‘Better than well’ psychopharmaceuticals (Prozac, Paxil, etc.) align an individual’s personality with prevailing cultural values. When a culture is competitive, aggressive, and garrulous, shyness and sadness are socially undesirable. There’s a pill for that.

In addition to culturally desirable personalities, there are culturally desirable bodies. Aesthetic cosmetic surgery aligns individuals with the physical appearance currently favored by their culture. This allows individuals to increase their cultural capital, as Bourdieu would say.

I include in this category the happiness/positive psychology movement and the self-help industry, since they also help individuals conform to prevailing social expectations. It’s no coincidence that positive psychology supports the current economic interests of society (see, e.g., this description of the medical profession’s responsibility to boost worker productivity by increasing the happiness of patients).

Continued in part two, where I describe the remaining three topics: corporatism, neoliberalism, and the social determinants of health.

References:

Kimberly M. Lovett and Bryan A. Liang, Direct-to-Consumer Cardiac Screening and Suspect Risk Evaluation (PDF), JAMA, June 22/29, 2011, vol 305, no. 24, pp 2567-2568

Micki McGee, Self Help, Inc.: Makeover Culture in American Life (2007)

William Davies, The Political Economy Of Unhappiness, New Left Review, 71, September-October 2011

Guest post: The unemployed as the waste products of the success factory

Jan — Mon, 16 Jul 2012 06:07:15 +0000

Pierre Fraser is an author, essayist, and PhD candidate in sociology at Université Laval. We share an abiding interest in healthism or, as Pierre would say, santéisme. For the original version of this post, see L’individu devenu déchet. Pierre blogs at Pierre Fraser and tweets as @pierre_fraser.

Unlike some countries these days, America seems to have little difficulty tolerating the idea of multiculturalism. An explanation for this, perhaps, can be found in the American ideology of success. This ideology acts like a suction pump, removing any alternative explanations of how the world should work. This myth is contagious. The American dream – you can be whatever you want to be – circles the globe like a very powerful trademark.

In the myth of the self-made man, everything is possible. So powerful is this belief that nothing seems able to deter it. Contact with this idea creates the equivalent of an addiction. Every addiction, however, has its downside. We forget that every day “two types of trucks leave the factory: one type goes to the warehouse and department store, the other to the landfill. We have grown up with a story that considers only the first truck and ignores the second. ” [1]

The ideology of success creates a blindness that is pernicious. The media glorify successful people, especially those who struggle against overwhelming odds and are ultimately victorious. Small and insignificant individuals are transformed into the powerful. They are the American heroes. When the media talk about success, however, they ignore the army of the unemployed. These waste products of the success factory — those destined for the landfill — have, after all, failed.

Since the beginning of the industrial era, the unemployed have functioned as the reserve army of labor. They survived with the hope that someday they would surely be recalled from unemployment into active service. Today, however, the destination of those who become unemployed is the landfill of poverty and the psychological trash heap. As Danièle Linhart points out, “these men and women not only lose their jobs, their projects, their dreams and the assurance of a life under their control: they are also deprived of their dignity as workers, their self-esteem, their sense of purpose and their place in society.”[2]

My colleague Georges Vignaux and I would like to understand just what is happening here. What does the future hold for those men and women who become the waste by-products of the success factory? Each time we look under the hood of this astounding mechanism, what becomes increasingly clear is that protest marches and riots seem to be the most appropriate mode of expression for those who have become fed up. Why, I ask you, should all these disqualified people respect the rules of the success game? If work rules are ignored by the very people who have laid them down, how can the unemployed not perceive this as an aggression and a gross injustice?

Perhaps what we are trying to understand here does not affect you. After all, you still have a job that allows you to have a nice house or a decent apartment. You can feed your family and entertain yourself. Maybe you tell yourself that those who are unemployed simply need to exert themselves — to do what it takes to find another job. The problem is, we have learned not to even consider the trucks going to the landfill. We choose to believe that everyone sees only those first trucks on their way to the department store and warehouse.

Just as storing industrial waste in refrigerated containers is no way to create valuable market commodities, storing the unemployed — letting them go to waste — in unemployment programs will not turn them into valuable employees for today’s market. Why? “When the protections afforded by the state against existential chills are gradually dismantled, when the institutions of collective self-defense, such as unions and other instruments of collective bargaining are losing their power under the pressure of economic competition that reduces the solidarity of the weak, it becomes necessary for individuals to seek, find, and develop individual solutions to social problems and to test them through individual actions like riots and protest marches. Such tools and resources, however, are inadequate when they are up against the mechanisms that have turned them into waste products.”[3] The destination of this process is quite obvious: programmed and scheduled poverty.

Thanks to Jan Henderson for this translation !

[1] Bauman Zygmunt, Vies perdues – La modernité et ses exclus, Paris, Éditions Payot, 2006, p. 55.

[2] Linhart Danièle, Rist Barbara, Durand Estelle, Perte d’emploi, perte de soi, Paris, Ères Poche, 2009.

[3] Bauman Zygmunt, Le présent liquide, Seuil, Paris, 2007, p. 24.

SCOTUS, the Affordable Care Act, and an ugly American tradition

Jan — Thu, 05 Jul 2012 21:38:58 +0000

I thought I had exhausted my need to read or listen to anything more on the Supreme Court decision on the Affordable Care Act (ACA). I read something today, however, that made me realize I hadn’t been paying close enough attention. It was an article published by The New England Journal of Medicine called The Road Ahead for the Affordable Care Act

The author, John McDonough, points out the significance of the upcoming November elections. In particular, he clarified for me why recent mentions of ‘reconciliation’ are not just referring to how the ACA was passed in 2010.

In January 2013, if Democrats hold the White House and Senate and regain control of the House, the ACA will be implemented mostly as constructed. If Republicans capture the White House and Senate and retain House control, the ACA will face major deconstruction early in 2013. Republican leaders will attempt to use Congress‘s budget-reconciliation authority to enact extensive repeal — and will need only 51 Senate votes, with no filibuster threat. If control of the White House and Congress is divided between the parties, then conflict over the law will persist. Thus, the November elections increasingly feel like a referendum on the ACA.

During this Fourth of July week we’ve had much flim-flam on the Court’s decision from the Romney campaign: “The mandate is a penalty.” “No, it’s a tax.” “The exact same mandate is not a tax in Massachusetts, however.”

There are reasons, then, why health care might not become a campaign issue for this particular Republican presidential nominee. And if it does not, I wonder if those in favor of universal health care realize how easily we could lose this historic achievement.

The subtleties of Medicaid

The Medicaid issue is a bit more nuanced than I’d been paying attention to. Currently Medicaid does not cover all legal residents with incomes below the federal poverty level. Forty-five states, for example, do not include adults who have no dependent children. The 2011 poverty guideline recommended by the Department of Health and Human Services was $10,890 for an individual in most states (that’s annual income and the cut off increases with family size). Although states are required to cover poor children, whether their parents are covered varies by state. According to the Los Angeles Times: “As of 2009, 17 states only covered working parents who made less than half the federal poverty line, or $5,415.” In Arkansas a working parent must earn less than $1,841 to qualify for Medicaid. It’s hard to imagine buying much of anything, let alone health insurance, on an annual income of $1,841.

The intent of the ACA was to expand Medicaid coverage in two ways: It would increase the income cut off to 138% of the poverty line and it would be available to everyone in that income category, including those not previously covered.

The Supreme Court ruling allows states to refuse this expanded coverage and to continue with their previous Medicaid rules. Residents in such states with an income between 100 and 138% of the poverty level would be eligible to obtain health coverage through insurance exchanges. Those below the federal poverty level, however, would not. As McDonough writes, the Supreme Court decision

creates a new inequity in the health system: by 2014, all Americans will have guaranteed access to affordable health insurance except adults with incomes below the poverty level who were previously ineligible for Medicaid.

McDonough also clarifies an aspect of the financial motivation behind opposition to the individual mandate. Currently there are individuals who are eligible for Medicaid, but who have not signed up. Governors of conservative states fear that the mandate will induce those individuals to apply for Medicaid. This will increase state expenses (the federal government pays matching funds of 50 to 83% of the cost of Medicaid, leaving states with the remaining 17 to 50%). “Disagreement over how many such people will enroll helps to explain the wide divergence in estimates of the costs to states of expanding Medicaid,” writes McDonough.

The ugly tradition

In looking over some of my previous posts on health care reform, I came across the following comment on opposition to the individual mandate. It addresses an underlying issue that explains why it has been so difficult to achieve universal health care in the US. Written by David Cole, it was published in February, 2011 following a ruling against the individual mandate by Virginia federal judge Henry Hudson. (emphasis added)

The roots of the ideological divide, moreover, run deep. The principal constitutional issue at stake—the extent of Congress’s authority to pass laws governing Americans’ lives—has separated conservatives and liberals since the beginning of the Republic. “States’ rights” was the South’s rallying cry in its effort to retain slavery before the Civil War, and to defend racial segregation from federal intervention thereafter. From the turn of the century through the early years of the New Deal, conservatives successfully invoked “states’ rights” to interpret Congress’s power over interstate commerce narrowly and thereby invalidate progressive federal laws designed to protect workers and consumers from big business. …

Opposition to health care reform is ultimately not rooted in a conception of state versus federal power. It’s founded instead on an individualistic, libertarian objection to a governmental program that imposes a collective solution to a social problem. While Judge [Henry] Hudson’s reliance on a distinction between activity and inactivity makes little sense from the standpoint of federal versus state power, it intuitively appeals to the libertarian’s desire to be left alone. But nothing in the Constitution even remotely guarantees a right to be a free rider and to shift the costs of one’s health care to others. So rather than directly claim such a right, the law’s opponents resort to states’ rights.

In this respect, Judge Hudson and the Virginia attorney-general are situated squarely within a tradition—but it’s an ugly tradition. Proponents of slavery and segregation, and opponents of progressive labor and consumer laws, similarly invoked states’ rights not because they cared about the rights of states, but as an instrumental legal cover for what they really sought to defend—the rights to own slaves, to subordinate African-Americans, and to exploit workers and consumers.

Here, too, opponents of health care reform are not really seeking to vindicate the power of states to regulate health care. Rather, they are counting on the fact that if they succeed with this legal gambit, the powerful interests arrayed against health care reform—the insurance industry, doctors, and drug companies—will easily overwhelm any efforts at meaningful reform in most states. Unless the Supreme Court is willing to rewrite hundreds of years of jurisprudence, however, they will not succeed.

Back in the swing?

I started writing this blog in October of 2008, a month before President Obama was elected. I hadn’t anticipated writing about health care reform, but it was soon hard to avoid.

I’ve been on a self-described ‘sabbatical’ from blogging for the past year. In the next post, I explain why I may be ready to start writing again. Although I don’t plan to write about the politics of health care, my reasons for resuming are inspired by the issues of health care reform: a desire for collective solutions to social problems and the elimination of an ugly tradition that affects not only health care, but health itself.

Resources:

John E. McDonough, The Road Ahead for the Affordable Care Act, The New England Journal of Medicine, July 2, 2012

Noam N. Levey, Court’s decision could widen Medicaid gap, Los Angeles Times, June 29, 2012

David Cole, Is Health Care Reform Unconstitutional?, The New York Review of Books, February 24, 2011

Update 7/9/12: More on Medicaid

There’s something I neglected to mention about the Supreme Court’s decision with respect to Medicaid. The provisions of the ACA stipulated that if a state refused to expand Medicaid (generously funded by the federal government), it would lose its Medicaid funding. The Supreme Court ruled that this was too coercive and that states could retain their current Medicaid funding even if they refused to expand it.

Texas governor Rick Perry announced today that Texas would reject the expanded Medicaid program. Texas has 6.2 million uninsured residents, almost a quarter of its population.

Another nuance, highlighted in a Forbes article today: Another provision of the ACA was that states must not reduce their Medicaid eligibility rules (some states have eligibility levels that are “well above federal minimums”). If they did, they would lose their Medicaid funding from the federal government. This was struck down by the court.

Yet another provision of the ACA (it’s a big document) requires states to set up health insurance exchanges. If they do not, the federal government will create one for them. Governor Perry also announced today that Texas would not set up a state insurance exchange.

In states like Texas that reject both Medicaid expansion and state exchanges, residents who lose their Medicaid coverage will be eligible for insurance through the new federally funded exchanges. The Forbes article describes the financial implications of this for insurance companies (bad for Medicaid health plans) and the pharmaceutical industry (good because exchanges will pay more). But there’s another angle. Getting more people covered by federal health exchanges is (it seems to me) a back door to universal coverage/single-payer/Medicare for all. That would be a very good thing indeed.

Update 7/11/12

A very satisfying editorial from the Post’s Matt Miller:

GOP to the uninsured: Drop dead (Washington Post)

The Republican message to uninsured Americans in the wake of the Supreme Court’s recent ruling couldn’t be clearer: You’re on your own. … The party may not have officially adopted the “let him die” policy of right-wing hecklers at that CNN primary debate, when Ron Paul was asked what should be done when an uninsured man shows up at the hospital. But as a practical matter, Republicans are in pretty unsavory territory. What other conclusion can we draw when Rick Perry, who presides over a state where one in four people lack health coverage, makes swaggering indifference to these Texans’ plight a point of sovereign pride? …

Only in America could a Democratic president pass Mitt Romney’s health plan and fund it partly through John McCain’s best idea from the last campaign (taxing some employer-provided plans) and be branded a “socialist.”

Miller goes on to point out that there are more uninsured Americans than the combined populations of 25 states.

What is healthism? (part two)

Jan — Mon, 20 Feb 2012 23:20:10 +0000

In 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, it’s 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.

What is healthism? (part one)

Jan — Mon, 20 Feb 2012 22:20:15 +0000

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.

Anti-authority healthism

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.

Guest post: Is the prevalence of depression related to the modern empowerment of the individual?

Jan — Sun, 19 Feb 2012 22:13:57 +0000

Pierre Fraser is an author, essayist, and (currently) a PhD candidate in sociology at Université Laval. Just as his most recent book (Tous Malades !: Quand l’obsession pour la santé nous rend fous) was being published, I met Pierre on Twitter, where we discovered our mutual interest in the subject of healthism. Pierre blogs at Pierre Fraser and tweets as @pierre_fraser.

This translation would have been impossible without the invaluable assistance of Jan Henderson (PhD in the history of science and medicine from Yale). Her work allowed me to revisit the original French text and enhance it, and in this sense, we followed the injunction of Karl Popper : the duty of clarity. I hope our collaboration will continue, because Jan and I are particularly concerned about the healthization of society, and we try to understand how health has become a social value. Feel free to send us your comments (Jan Henderson, Pierre Fraser).

Pierre Fraser, 2012

When a medical clinician examines a patient, she first determines the presenting symptoms, considers which bodily functions might account for those symptoms, arrives at a diagnosis, and provides the most appropriate treatment. But what if the presenting symptom is depression? As Alain Ehrenberg points out, “depression, like any mental illness, is not a disease that can be assigned to a part of the body.” [1] In fact, as Ehrenberg goes on to say: “when psychiatry can discover the cause of a mental illness, as happened with epilepsy, it is no longer a mental illness.” [2] Such has been the dilemma of the history of psychiatry.

Consider, though, what has happened in the history of depression. Seventy years ago an individual who suffered from depression was considered sick, but curable. Today our assessment is that such an individual has a chronic disease. [3] How can we explain this historical progression?

When we look closely at the history of psychiatry it teaches us one thing very well: “disagreements about the causes, definitions and treatment of diseases, as well as the uncertainties that have accompanied the history of psychiatric reasoning, are particularly revealing about the transformation of the individual.” [4] Since the beginning of the Industrial Revolution, our concept of the individual has undergone fundamental transformations. Given that we now hold “the gospel of personal development in one hand and the cult of performance in the other” [5], we can see that “the history of depression reveals how the type of person we have become has followed in the wake of demands for psychic emancipation and individual initiative. What insanity is to reason and neurosis is to conflict, depression is to insufficiency.” [6] Emancipation and empowerment bring the expectation that the individual will perform. But will that performance be adequate? Depression is the result of feeling that our life’s performance is not sufficient.

A social bond in crisis

The Age of Wild Capitalism (1860-1929) was dominated by the captains of industry. Private enterprise reigned supreme and regard for the individual was at the same level as regard for commercial merchandise. This was followed by the Age of Democratic Capitalism (1930-1973), when the state, in response to the Great Depression, began to intervene in markets by imposing regulations. The Age of Supercapitalism (1973-2005) began with the first oil crisis. The economic difficulties of the era created an opportunity for President Ronald Reagan and Prime Minister Margaret Thatcher to deregulate a variety of economic sectors. The period culminated with globalization. Finally, I would like to propose that we are now in an Age of Distributed Capitalism [9] where the dominant influence will be high-tech industries. This stage will enable the complete empowerment of individuals: they will be fully in charge of their lives through the use of inexpensive and widely available technologies.

In this table what stands out first and foremost is a correlation between the dominant ideology of each era and the relative hierarchy of the players. In the Age of Democratic Capitalism, the state is the most prominent social actor. Entrepreneurs and financiers are relegated to the bottom of the scale. This is a complete reversal of the positions they held in the previous age. The reversal is apparent not only in the rise of unions, but in the implementation of major social protection programs that are characteristic of this age. Though these programs took on different forms in different countries, the intention was the same. We see here an example of what Durkheim called ‘organic solidarity’: a social cohesiveness and interdependence that arises from the division of labor. This state of affairs allows individuals to benefit from the basic protections of society while feeling their contributions are valued as useful. [10]

On the grammar of depression

The Age of Democratic Capitalism appears, at first glance, to be highly favorable for the individual. Thanks to various social measures, it was a time when the state offered increased protections against life’s misfortunes. Living conditions improved for all economic classes. Purchasing power increased annually, and “those born after 1945 not only have the best physical health in modern history, but have also been raised in a period of unprecedented prosperity.” [11]

It might seem paradoxical that the prevalence of depression would increase in this era, but this was definitely the case. In 1989, the American Medical Association published a summary of epidemiological studies of depression and concluded: “the increased risk of depression for those born after the Second World War is indisputable.” [12] There had been an astonishing amount of material progress, yes, but this was accompanied by “urbanization, geographic mobility, emotional breakdowns, the growth of social anomie, changes in family structures, and the embrittlement of gender roles.” What is especially interesting about the epidemiological studies is that they all converge on the same explanation for the rise of depression: social change.

We must admit that social change alone cannot explain everything about depression. There must also be a ‘grammar of depression’ through which individuals may conduct their own diagnoses, and this grammar can only exist if depression is institutionalized. Around 1960 “anxiety, insomnia and overwork as the themes of depression appear publically in major magazines.” [13] They provide “an interpretive tool to solve or overcome intimate problems.” [14] In other words, depression involves actors who supply the hows and whys of their problems, while mass media tell people how to deal with those problems. Depression is thus “produced in a collective construction that provides it with a social framework in which it exists.” [15] Depression becomes a social reality and a “grammar of the inner life for everyone.” [16] Once individuals understand that they are subject to depression, however, there is a social crisis. If individuals regard themselves as depressed, will they be able to perform the roles expected of them by society? A society functions best when its members feel that what they are doing is useful. Depression, with its sense of the insufficiency of the individual, calls this into question. A society needs motivated, mentally healthy citizens, but will it be able to alleviate the widespread incidence of depression?

As Alain Ehrenberg has emphasized, “democratic modernity — this is its power — has gradually turned us into men who have nothing other than our own selves to guide us. We are gradually put into a position where we have to make our own judgments and create our own standards.” [17] The possibility of living our lives as sovereign, autonomous individuals has not only become a reality for some of us, as anticipated by Nietzsche, but is now the common reality for everyone. In times past, an individual who did not respect the rules (what is permitted/prohibited) was seen as guilty of a ‘sin.’ Today, however, he is blamed for a ‘failure of responsibility’ (what is ‘possible/impossible’). The individual can no longer agree to accept the label ‘guilty’ without giving it much thought. The sovereign individual must feel the weight of responsibility for his actions. This reconfiguration of the individual self brings us back to the contemporary prevalence of depression. As Ehrenberg points out, depression is now something intrinsic to the individual: “it is the failure of internal resources.” [18]

About depression

It is quite possible that depression is an anomic condition (Durkheim). That is, it occurs in contexts where the individual, confronted with the duality “possible/impossible,” feels he must “be himself,” but he lacks the “instructions” for how to accomplish this. We are no longer expected to conform to an obvious discipline. We are required to “be ourselves.” Depression, as Durkheim suggests in connection with suicide, arises from the “malady of infinite aspiration,” where everything seems possible, but in fact, nothing is possible.

To answer the basic question with which I began — whether there is a causal link between depression and the increasing empowerment of the individual — it seems plausible to say yes, given that “projects, motivation, and communication are now norms that dominate our culture.” [19] “Depression becomes, so to speak, how the individual safeguards himself. It acts as a kind of counterpart to all the energy that must be exerted simply to maintain the self as sovereign.” [20]

© Pierre Fraser & Jan Henderson, 2012

[1] Ehrenberg Alain, La fatigue d’être soi, dépression et société, Odile Jacob (poches), Paris, 2000, p. 21.

[2] Idem, p. 22.

[3] Idem, p. 251.

[4] Idem, p. 22.

[5] Idem, p. 255.

[6] Ibidem.

[7] I designed this table in 2009 — to gain an overview of the historical eras — when I co-authored the book “Les imbéciles ont pris le pouvoir, ils iront jusqu’au bout !” Published by “Near Future.”

[8] Krugman Paul, L’Amérique que nous voulons, Flammarion, Paris, 2008, p. 352.

[9] This is currently a speculative proposition that must be supported by empirical evidence from current trends.

[10] Durkheim Émile, De la division du travail social, eBooksLib on iBookStore, iPad version, p. 377.

[11] Ehrenberg, 2000, p. 142.

[12] Ibidem.

[13] Idem, p.143.

[14] Ibidem.

[15] Ibidem.

[16] Idem, p. 145.

[17] Idem, p. 15.

[18] Idem, p. 177.

[19] Ibidem.

[20] Hadler Nortin M., Malades d’inquiétude ?, translated from English by Fernand Turcotte, MD, Québec, PUL, 2010, p. 1.

Why medicine is not a science and health care is not health

Jan — Mon, 31 Oct 2011 04:00:01 +0000

Here’s something I read recently in a blog post (The Limits of (Neuro)science at Neuroskeptic) that started me thinking:

Will science ever understand the brain? …

The notion that humans are complex and hard, while nature is easy, is an illusion created (ironically) by the successes of reductionist science. Some of the biggest questions facing mankind for eons have [been] answered so well, that we don’t even see them as questions. Why do people get sick? Bacteria and viruses. Why does the sun shine? Nuclear fusion. Easy.

I started to write a simple reply, but it grew into the following.

Medicine is an applied science, not a pure science

It may be true that understanding the human brain is only an order of magnitude more difficult than understanding any other aspect of human biology. I’m uneasy, however, about putting ‘why people get sick’ in the same category as ‘nuclear fusion.’ Particle physics is a science. Questions can be asked and (usually) answered under the controlled conditions required by the objectivity that characterizes science.

Medicine is the application of certain sciences (molecular biology, biochemistry, medical physics, histology, cytology, genetics, pharmacology, neuroscience) to – ultimately — individuals. Each individual is the product of a unique, lifelong sequence of social, cultural, economic, and psychological (as well as physical, chemical, biological, and genetic) influences. To this day, we don’t really know why some people get sick and others do not. To my mind, that makes medicine an application of science – like engineering – not a science in itself.

Take bacteria and viruses. It’s true that pathogenic bacteria can make people sick, but what’s interesting is that they don’t always. Inspired by the germ theory of disease, medicine in the late 19th century held that a specific disease must have a single cause. The cause of tuberculosis was the tubercle bacillus: if you had the ‘germ’ you must have the disease. By the 1930s, medicine began to acknowledge that diseases could have multiple causes. And by the mid-20th century, medical textbooks explained that the presence of the tubercle bacillus did not always lead to TB. The bacillus was a necessary ‘seed,’ but the patient was the ‘soil’ in which the seed might or might not grow.

Does the scientific nature of medicine limit its potential?

I admit there may be large, indefensible holes in the assertion that medicine is not a science. How different is it from geophysics, which studies the earth and its environment (including the earth’s climate)? Isn’t that a science? Yes, because it adheres to the scientific process of measuring observable data, publishing the results for peers to review, and not giving credence to mere opinion. Surely the same could be said of medicine.

My real objection to medicine as a science is that by focusing on what can readily be quantified, it ignores what cannot, such as the social determinants of health and disease. Medicine’s historical desire for the respectability that comes with being a science gets in the way of discovering what could actually make us healthier.

Health care does not create health

Although we don’t know why some people get sick and others do not, we have some ideas. It could be what we eat, the quality of the air we breathe, our occupation, how much we earn, whether we feel our situation in life is fair, how we were treated as a child, numerous sources of stress in our lives.

Science prefers to isolate and understand one thing at a time, but the ideas I just mentioned are difficult to separate from their social context and cannot readily be studied in a controlled environment. The topics for medical research that seek and receive funding are those that investigate ‘reductionist’ theories of disease: things that fit neatly into categories sanctioned by the medical establishment and that can be readily measured, compared, and replicated. The cause and effect relationship between stressful living conditions and the health of individuals does not fit neatly into any simple mechanical model with the potential to make successful predictions.

For political reasons, it’s safer for medical research to stick to the limited agenda of what’s easily measured. If researchers investigated the social determinants of health, the answers could prove disruptive or inconvenient for prevailing economic (and thus political) interests. I’m thinking here of things like reducing air and water pollution, keeping carcinogens out of the food supply, and making sure drugs are safe before they’re prescribed for a large segment of the population. (The negative externalities of corporate culture, in other words.) It’s quite likely that social determinants of disease are extremely important for health. We don’t know for sure, not only because they’re hard to measure reliably, but because pursuing them tends to be politically unpopular.

Health care systems, informed by the scientific categories of medicine, are not designed to deal with things that cannot be easily quantified. Health care policy is set by politicians whose financial interests have been known to trump the common good. What preventive health care is good at these days (as opposed to the days when there was time for the doctor-patient relationship to offer comfort and relief) is creating guidelines for unacceptable levels of blood pressure, cholesterol, or blood sugar and prescribing drugs when tests indicate a patient has crossed an arbitrary but measurable threshold. That, and shift the blame for poor health onto the lifestyles of individuals, and be very expensive.

This is short-sighted.

A society that spends so much on health care that it cannot or will not spend adequately on other health-enhancing activities may actually be reducing the health of its population.

We need to figure out a way to liberate health from the financial interests that drive health care. Until then we’re stuck with a system that cares more about profiting from the narrow agenda of scientific medicine than it cares about improving health.