Take two aspirins and thank your caring PM

December 19, 2003

The THES serves up six pages of reflections on some of the changes that have been making many people in our society feel increasingly anxious and frightened

Health used to be an issue for a person and his doctor, now the government is using it to reach out to an alienated electorate, says Michael Fitzpatrick

This month it was children dying from Fujian flu, women at risk of breast cancer from taking hormone replacement therapy and yet another bioterrorism alert in London. Last month it was "cancer fears over baby food jars" and the "timebomb" of childhood obesity. We can be sure that the Christmas period will bring seasonal panics about binge drinking and sexually transmitted diseases passed around after office parties, as well as some novel scares.

Though people in western societies today live longer and healthier lives than at any time in human history, we are uniquely preoccupied by our health and the measures considered necessary to preserve it. Anxieties about health are expressed in the fashion for physical exercise and the popularity of health-screening programmes, diets and supplements. Yet these and numerous other health-related activities do not seem to alleviate existential anxieties. The resonance of an apparently endless series of panics over issues from mobile-phone masts to genetically modified foods reflects the high level of free-floating anxiety in society.

Now that "public-health messages" are planted in TV soap operas, doctors cannot ignore the popular media. The result of public awareness of hitherto little-recognised conditions from Alzheimer's to Asperger's is a steady influx of the "worried well" into doctors' surgeries.

Two questions arise from the upsurge of health-related anxieties, which are often the direct result of government-sponsored health-promotion initiatives. Why is the government (with the support of leading medical authorities and institutions) so keen to intervene in the intimate lives of its citizens in relation to issues of health and health-related behaviour? And why is there such a popular clamour for such interventions?

Given the state's huge role in health promotion, it is worth emphasising that this level of intervention in personal life is historically unprecedented outside wartime. In the 1950s and 1960s, when it first became clear that there was a causal link between cigarettes and lung cancer, politicians were reluctant to take steps to deter smoking. No doubt this was largely attributable to fiscal and electoral considerations. Yet it would be a mistake to underestimate the role of popular traditions of suspicion of any official incursions into individual behaviour, even in the cause of improving health.

There was also some reticence among the medical elite about official intrusion into the personal domain. Thus the publication of the Royal College of Physicians' 1962 report recommending a public campaign against smoking followed a struggle between an incoming modernising leadership against an old guard personified by Lord Russell Brain, the eminent neurologist. Brain "doubted very much" whether "going beyond the facts" to "giving advice to the public as to what action they should take in the light of the facts" should be the function of the college.

The first major state intervention in health promotion was the document Prevention and Health: Everybody's Business , produced under Labour health minister David Owen in 1976. Its central theme was that "much of the responsibility for ensuring his own good health lies with the individual".

In Eating for Health in 1979, the government claimed that an unhealthy lifestyle resulted from ignorance and irresponsibility and emphasised the need for information and education to change behaviour.

Owen's preventive strategy made little impact. As a minister he was unpopular with both the medical profession and the trade unions. Given the strength of the collectivist traditions of the labour movement, the individualistic sentiments so bluntly expounded in the reports found little popular resonance. They also provoked a vigorous radical response as critical sociologists condemned the "medicalisation" of daily life, the "victim-blaming" character of much health-promotion propaganda and the evolution of medicine to become "an institution of social control". It was not until more than ten years later that another government turned again towards health promotion - with dramatically different results.

The success of the "tombstones and icebergs" campaign to raise awareness of Aids in the late 1980s showed prime minister Margaret Thatcher the political potential of health promotion, which her successor, John Major, pursued through the Health of the Nation policy introduced in the early 1990s. This comprehensive health-promotion programme had more effect than its predecessor in terms of the targets the policy set. Yet whether or not individual behaviour changed, the fact that in the course of the 1990s the smoker came to be regarded as a pariah reflected the wider impact of the climate of opinion around issues of health that this policy did much to encourage.

The greater impact of official health-promotion propaganda in the 1990s compared with a decade earlier also revealed the enhanced sense of individual isolation that resulted from the Thatcher years. This was the result of a number of factors, including mass unemployment, the resulting job insecurity and the increasing fragility of family relationships. The breakdown of institutions and traditions of collectivity in the 1980s, best exemplified by the defeat of the trade unions, exacerbated the fragmentation of communities. The individuating dynamic resulting from unleashed market forces had destabilising consequences throughout society and led to a heightened sense of personal vulnerability that often found expression in fears about health.

Government intervention in health today reflects the further estrangement of the state from the individual in society. As a result of global economic and political trends, the domestic political sphere has declined dramatically in significance and the public has become increasingly disengaged from the political process. The decay of collective organisations, in politics and in other spheres, has accelerated and individuals have become ever more isolated and atomised.

Finding little scope for their initiatives in economic policy or foreign affairs, and trying to overcome a sense of aloofness and loss of respect in society, politicians have turned to health. But whereas old Labour politicians' interest in health lay in building hospitals and improving health services, new Labour politicians are interested in health as a means of establishing points of contact between themselves and the remote individuals who make up the electorate. Today, health no longer means measures to develop the National Health Service, it means schemes to change individual lifestyles in the name of improving health - through more restrictions on smoking in public, proposals to curtail sales of junk food to children, measures to fight binge drinking and campaigns to encourage early detection of cancer.

Though official health promotion campaigns have become more sophisticated over the years (notably in toning down the old-style moralistic, victim-blaming rhetoric), the inclination to exploit popular fears to change behaviour is a consistent theme.

However, the major change has been in the popular response to such campaigns. Whereas Owen's proposals in the 1970s were scorned by the unions, coolly received by doctors and condemned by radical sociologists, today's climate is very different. To the extent that they still exist, trade unions have embraced health and safety issues; doctors' organisations are much more sympathetic towards government policy; when the public finds a voice, this tends to be used, not to repudiate state intrusions individual autonomy but to demand more of the same. (Thus, the government's relatively restrained line over the epidemic of severe acute respiratory syndrome last winter was overridden by popular demands for more drastic measures.) Tony Blair has claimed the establishment of NHS Direct, a 24-hour, nurse-led telephone advice service, as one of the major achievements of his first term as prime minister. This symbolic "one-to-one" communication, between the anxious citizen worried about some health-related problem and a proxy for the caring, listening prime minister, is a potent image of the new therapeutic relationship between the government and the people. The success of NHS Direct reveals the need of the vulnerable individual for solace and reassurance, and the desire of a government that lacks authority and legitimacy to establish points of contact with an increasingly atomised and alienated electorate.

Michael Fitzpatrick is a GP in Hackney, East London, and author of The Tyranny of Health: Doctors and the Regulation of Lifestyle , Routledge, 2001. His book MMR and Autism: What Parents Need to Know (also from Routledge) is due out early next year.

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