As the government announces its plans to increase life expectancy, Dr Michael Fitzpatrick asks - who wants to live even longer under New Labour's grim health regime?
The tyranny of health
Our Healthier Nation: A Contract for Health, the latest declaration of the government's commitment to the promotion of health and the prevention of disease, offers the prospect of a longer life - but at the cost of an even more extensive and intrusive system of state regulation of individual behaviour.
Following the Conservative government's Health of the Nation initiatives of the early 1990s, New Labour has set targets by which progress can be measured - in reducing rates of heart disease and strokes, accidents, cancers and suicides. Much commentary on the proposals has focused on the drastic reduction in the number of targets and the new government's more modest ambitions (no doubt influenced by its failure to meet many of its notoriously cautious election promises). But a more significant feature of Our Healthier Nation is that it puts forward a strategy - previously lacking - to link national targets to local initiatives and outlines plans to pursue health goals in schools, workplaces and neighbourhoods. It thus aims to supplement exhortations to behave virtuously (stop smoking, curtail drinking, take exercise, eat healthily, etc, etc) with an effective system of regulation of behaviour.
The positive response to Our Healthier Nation, from the medical profession and the media in general, indicates the widespread acceptance of its basic assumptions. Before considering some of the government's specific proposals, we need to question the underlying principles. We can begin by noting a striking paradox: the government's preoccupation with health promotion appears to have grown in inverse proportion to the improvement in the nation's real state of health. To put this another way: at a time when, by any objective criterion, people enjoy better health than at any time in human history, the government appears driven to ever-greater intervention to improve people's health. Why?
Take life expectancy: the commitment to increase it is the first of the 'aims' proclaimed by Our Healthier Nation. As this is widely taken as self-evident, it receives no justification. But why should this be the ultimate target of medical science, let alone of government policy, least of all at a time when the increasing longevity of the population has become a widely acknowledged social problem?
A boy born in Britain today can expect to live until he is nearly 75; a girl till over 80. Life expectancy has increased by more than 30 years over the past century and around a decade since the Second World War, apparently without the benefit of New Labour-style measures of health improvement. It is clear that we have not only exceeded the biblical lifespan of 'three score and ten' but that more and more of us are moving closer and closer to the biological limit of the human species.
There is much scientific debate about whether further increase in life expectancy is possible. But is it desirable? The raging popular controversy over euthanasia, the romanticisation of suicide among young men (such as rock stars Kurt Cobain and Michael Hutchence) and the vogue for mass suicide among followers of millenarian cults suggest a widespread tendency to opt for a shorter rather than a longer life. The desire to live longer by taking health precautions may be interpreted as another way of responding to the perception that life in modern society lacks meaning and purpose. As Theodore Dalrymple puts it in his recent book on health scares, 'no wonder then that modern man seeks to prolong his life a little, for it is all he has' (Mass Listeria: The Meaning of Health Scares, 1998). For Dalrymple this explains the way that people 'react to any threat with fright - no, with existential terror'.
Advocates of the 'new public health', the medical discipline based on PC moralism and dodgy statistics which is in the vanguard of New Labour's health crusade, will object that their emphasis is not so much on ensuring that people live longer as on preventing premature deaths. They will point out that, even though there is an average life expectancy of 75-80, more than 90 000 people die every year before the age of 65. Furthermore, some 32 000 of these deaths are from cancer and 25 000 from heart disease and strokes, many of which could have been prevented. It is worth reminding our earnest friends that, in fact, death cannot be prevented, only postponed. Unfortunately, given the current state of medical science, it can generally be postponed for a relatively short time by relatively intensive preventive measures.
This is the central weakness of the new public health: the scope for significant postponement of death from the major causes of premature mortality by preventive measures is limited, though the costs are often substantial. Thus, for example, the increase in average life expectancy to be gained from a 10 per cent reduction in the level of serum cholesterol in the population at large (a much vaunted target of the 1992 Health of the Nation white paper, though significantly absent in the latest document) is between 2.5 and 5 months (British Medical Journal, 16 April 1994). However, even to achieve this degree of reduction in cholesterol would require either drastic dietary modification or long-term drug treatment (with its attendant side effects).
Our earnest friends will further object that their aim is not only to increase life expectancy, but also to 'increase the number of years lived free from illness' - in the words of Our Healthier Nation. Now it is true that the fact that old people live longer does not necessarily mean that they suffer worse health (a fact commonly denied by the new public health allies of New Labour when they cite the 'rising burden' of health care for the elderly on the exchequer as a justification for rationing resources). However, it is also true that there is a tendency for the prevalence of common chronic degenerative conditions - heart disease, stroke, cancer, osteoarthritis, diabetes, dementia - to increase with age.
What is by no means clear is the contribution of the various preventive measures favoured by the government to improving the quality - as distinct from the duration - of people's lives. Indeed it may well be the case that an elderly person's enjoyment of a cigarette, a cream bun and a bottle of Guinness is more important to them than the extra few weeks they might spend in a life of miserable abstinence.
The second aim of Our Healthier Nation is to 'narrow the health gap' between rich and poor by concentrating efforts on improving the health of the 'worst off in society'. Here is another paradox: the government (and the medical profession) has become more preoccupied with the relationship between inequality and health at a time when social differentials in health are less significant in real terms than ever before.
No doubt it is true that people who are better off are healthier and that the poor are iller. A vast edifice of epidemiological data has been erected in recent years substantiating these differentials in great detail in relation to every disease and health indicator. Yet simply contrasting the health gap that exists in Britain today with that between rich and poor in Victorian England, or that which still prevails between Western and Third World countries, is enough to expose the lack of historical or social perspective in the contemporary public health debate.
Take infant mortality, one of the most intensively studied indices of population health. The persistent gap between the rate of infant deaths among rich and poor has been a particular focus of the promoters of the new public health since the publication of the Black Report in 1980 (now republished as Inequalities in Health, the Black Report and the Health Divide, 1992). The 1990 figures reveal that the number of babies whose fathers are classified as 'unskilled workers' (social class V) who die in the first year of life is 11.7 per 1000 live births, whereas that among the professions (social class I) is 6.2 per 1000 (Mortality Statistics 1990, Perinatal and Infant: Social and Biological Factors, 1992). In other words, the infant mortality rate for the poor is nearly twice that among the rich.
While there can be little doubt that the persistence of this differential is a pernicious effect of Britain's class divided society, it is important to place it in a wider context. The overall rate of infant deaths in Britain in 1990 was slightly less than eight per 1000 live births, by 1996 it had fallen below six. At the turn of the century the figure was around 150, by the Second World War it was still above 50; it did not fall below 20 until the 1960s (AH Halsey ed, British Social Trends since 1900: A Guide to the Changing Social Structure of Britain, 1988). In some Third World countries today, the infant mortality rate remains comparable with that of Britain in the early decades of this century: for example, India - 94, Bangladesh - 114, Egypt - 61, Mali - 164 (Alastair Gray ed, World Health and Disease, 1993).
Infant mortality has fallen precipitously among all social classes in Britain in the course of the twentieth century. In 1922 infant mortality among unskilled workers was 97; for the children of professionals, the rate was 38 (see Halsey). Over the past 70 years, the rate for the worst off has fallen further - by 88 per cent, compared with 84 per cent for the better off. The infant mortality rate of the poorest children today is similar to that of the richest in the 1970s.
As the expert statistical manipulators of the new public health are well aware, it is possible, by carefully choosing your starting point and other manoeuvres, to reveal slight increases or decreases in class differentials in infant mortality. But what all such comparisons of mortality rates obscure is the dramatic decline in the absolute number of infant deaths.
In 1990 the total number of babies dying in the first year of life in England and Wales was 3390; in 1900 the figure was 142 912, in 1940 it was still higher by a factor of 10 and in 1970 more than four times greater (Mortality Statistics 1990 and Halsey). The 1990 figure included 248 born to parents in social class I and 243 to parents in social class V (the rate is lower in social class I because approximately twice as many babies were born in this category). Though infant deaths may be relatively more common in poorer families, they are very uncommon in any section of society.
A commonplace event within living memory in Britain, the death of an infant has now become a rarity. Furthermore many of these deaths result from conditions such as prematurity and congenital abnormalities, which are often difficult to prevent or treat, or are 'cot deaths', the causes of which are uncertain and for which preventive measures remain controversial. Again, it seems that the level of government and official medical intervention is out of all proportion to the scale of the problem.
The more closely you examine Our Healthier Nation, the more strange its focus on problems that are of vanishing significance appears. Though we have become familiar with the definition of health by the World Health Organisation as not merely the absence of disease, the conception of health put forward by the government seems to have little to do with disease at all. At the outset its new report defines good health as 'the foundation of a good life' (p7). This recalls the Victorian motto - 'a healthy mind in a healthy body' - and establishes a link between physical condition and moral character. It implies that self-discipline and abstinence, the 'mortification of the flesh', can improve the quality of life, in a sense by purifying the soul. Even more insidiously and offensively, it also implies that physical impairment or disease either expresses or entails moral turpitude, a 'bad' life.
However, by contrast with the Victorian notion of a link between individual fitness and national efficiency, New Labour's interest in health is not inspired by any wider social vision. On the contrary, it reflects the outlook of a society which has abandoned any grand project, in which the horizons of the individual have been reduced to their own body: 'No matter what goes wrong in life - money, work or relationship problems - good health helps sustain us. How often have we all heard somebody say that although things may not be going well - at least they have their health. Good health is treasured.' (pp7-8)
In this homily health is reduced to a source of consolation for people who have given up on any higher ambition. In a society of low expectations, the goal of human existence is redefined as the quest to prolong its duration.
Once health is linked with virtue then the regulation of lifestyle in the name of health becomes a mechanism for deterring vice and for disciplining society as a whole. Our Healthier Nation is really a programme for social control packaged as health promotion.
'Health is not about blame, but about opportunity and responsibility.' (p28) Here is a characteristic New Labour sentence, short and snappy, linking an apparently radical repudiation of old-fashioned 'victim-blaming' health promotion with a Blairite couplet adapted from the speeches of Margaret Thatcher. But what does it mean? Though at first sight this soundbite appears characteristically vacuous, in fact it repays closer examination.
The key strategic device of Our Healthier Nation is the 'contract for health'. This begins from the acknowledgement that past health promotion initiatives placed too much emphasis on simply exhorting individuals to change their behaviour. It explicitly recognises the contribution of the government and local agencies - councils, health authorities, voluntary organisations, businesses - towards achieving targeted improvements in health. A glance at the detailed proposals suggests that the opportunities largely fall to the government and local agencies and the responsibilities fall on the individual. Where there are opportunities for individuals, these turn out to be opportunities to fulfil responsibilities as defined by the government.
The document elaborates at considerable length the roles of different 'players' in the contract for health. For its part, in addition to providing the policy and legislative framework, the government also undertakes to evaluate the health implications of all its policies. Indeed it seems inclined to review its entire programme through the prism of health. Thus, for example, its 'tough measures on crime' may gain in popular approval by being presented as a contribution to public health.
For local 'players', collaboration between health and local authorities in 'health action zones' and in the pursuit of 'health improvement programmes' is the central theme. 'Healthy living centres', financed by £300 million from the national lottery, will seek to 'provide opportunities for local community action to improve health and for individuals to take responsibility for improving their own health' (p46).
When it comes to the individual there is little left to be said: 'it is finally up to the individual to choose whether to change their behaviour to a healthier one.' (p48) The vaguely menacing tone is complemented by a guilt-tripping reminder that 'individual responsibility is not just about our own health', and a warning about the dangers of passive smoking and setting a bad example to others - particularly by parents to their children.
The authoritarian dynamic contained in Our Healthier Nation becomes increasingly apparent when it moves from the discussion of aims and targets to the local 'healthy settings' in which the policy will be implemented and contract compliance enforced. 'The contract will only work if everybody plays their part and everyone is committed to fulfilling their responsibilities', the document declares in a tone chillingly reminiscent of a headteacher's lecture, a managerial pep talk or a vicar's sermon (p29).
In 'healthy schools', children will be subjected to 'awareness raising' in matters of health, in the same way as they are currently subjected to mind-numbing propaganda about drugs, parenting, safe sex. They will have their eating habits policed more forcefully by the chip police, to promote 'healthy eating', and will be dragooned into physical exercise. No wonder truancy is on the rise.
Meanwhile in their 'healthy workplaces', the children's parents will be doing their bit to improve the nation's health. The document provides a list of precise instructions for employees. They can 'play their part in following health and safety guidelines', 'work with employers to create a healthy working environment', 'support colleagues who have problems or who are disabled' and 'contribute to charitable and social work through work-based voluntary organisations' (p51). Why not get some extra exercise and wash the employer's car during the lunch break?
In case people have difficulty envisaging the role of the 'healthy living centre', Our Healthier Nation provides an example: a centre at Bromley by Bow in East London run by an evangelical vicar who has turned his church into an 'integrated community project', providing a day nursery, a cafe, education and care services and a Bengali outreach project. Such initiatives aim to provide 'an important means of raising local awareness on issues such as diet, smoking, drinking, drug misuse and physical activity'. A Department of Health circular commends the LIFE project in the Wirral, which aims to 'improve health and fitness, self-esteem and quality of life' by providing, among other things, 'mobile health screening in pubs and betting shops'(!), and health, fitness and relaxation courses.
While vast sums of money are poured into projects that use health to enhance social control, real health needs are neglected. Waiting lists are lengthening and people are suffering and dying waiting for routine hip replacements, cataract removal and heart surgery.
Instead of the 'seven deadly sins' we now have 'four targets for health'. In place of the priest, we now have the doctor, teacher, vicar, social worker and epidemiologist rolled into one public health policeperson patrolling our lives from one 'healthy setting' to another, from home to school to work, from cradle to grave, with special 'outreach' capacity to any 'settings' not currently under surveillance.
Far better to take the advice of Theodore Dalrymple: 'eat, drink and be merry, for you'll live to be 80 at least, which is a long time to worry over trifles.'
Older generations are already living longer and healthier lives, without any help from the public health police
Reproduced from LM issue 109, April 1998