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The Dangers of Healthy Living

These days everything from our diet to our sunbathing habits seems to be the subject of an official health promotion campaign. But do these medical panics improve public health? Or are they more about shifting responsibility for social problems on to the backs of 'irresponsible' individuals?
Dr Michael Fitzpatrick argues that health promotion has depicted disease as the modern wages of sin - and has turned medicine itself into a quasi-religious moral crusade

We live in strange times. People in the West live longer and healthier lives than ever before. Yet people seem increasingly preoccupied by their health. There is a widespread conviction that the modern Western diet and lifestyle are uniquely unhealthy and are the main causes of the contemporary epidemics of cancer, heart disease and strokes. The fears provoked and sustained by an apparently incessant series of public health scares, backed up by government and medical 'health promotion' campaigns, encourage a sense of individual responsibility for disease. The recent government white paper, The Health of the Nation, seeks to place health and disease at the centre of a new morality of everyday life.

Are the health scares justified in medical terms? Take two recent examples - the cot death panic following the tragic death of television presenter Ann Diamond's baby son last year, and the more recent wave of concern about sunbathing causing skin cancer.

In January, after coming under sustained media pressure skilfully orchestrated by Ms Diamond, the Department of Health launched a national campaign to advise parents of young babies to stop smoking, to avoid overheating them with blankets, and to put them to sleep lying on their backs. This advice followed surveys in New Zealand and Avon which reported fewer deaths from 'sudden infant death syndrome' after such guidelines were introduced.

British paediatric experts were openly sceptical about the cot death campaign (see editorial, British Medical Journal, 1 February 1992). They noted that initial cot death rates were abnormally high in both survey centres, wondering whether the apparent reduction in mortality would be transferable elsewhere. They noted too a dramatic decline in cot death rates in Scotland, where no such guidelines were promoted, over the same period. They were also concerned about the difficulty of distinguishing the effects of different 'risk factors' - sleeping position, temperature control, smoking and breast feeding. They also observed that the guidelines did not tackle a key risk factor in cot death and infant mortality from all causes - 'socioeconomic deprivation'.

Though nobody knows what causes cot deaths, the government decided, on the basis of evidence drawn from less than 80 cases, most in a country on the other side of the world, to launch a major campaign to tell people in Britain what to do to prevent such deaths. The main effect of this, apart from changing babies' sleeping positions (until they roll over), was to make mothers who smoke and have experienced a cot death feel even more guilty and depressed, and those whose babies are still alive intensely anxious.

Malignant moles?

The sun had scarcely made its premature appearance in June than the newspapers were full of gloomy warnings about 'malignant melanoma'. The Guardian's account of 'Britain's fastest growing skin cancer' was a typical example ('Have a good time...but first look at the bad side', 19 June):

'Within two decades the number of cases reported each year has more than doubled to at least 3000. Small wonder that doctors are calling for the return of the parasol and the pith helmet.'

John Illman's 'good health guide to holidays', which would make any sensible person stay at home behind hermetically sealed doors, included three columns on how to diagnose and prevent sun-related skin tumours.

Reviewing the sort of medical text ('disaster dermatology') that encourages such popular journalism, Newcastle dermatology professor Sam Shuster bemoans the way 'the poor British public is being terrified by descriptions of moles going malignant' ('Apocalypse now', BMJ, 18 July). He also notes the trend to reclassify benign disease as 'early malignancy...which has given us the spurious cures used to justify an incompetent and frightening screening programme'. No doubt this has also contributed to the dramatic increase in the incidence of melanomas. He condemns an 'ill-conceived propaganda exercise' which has flooded skin clinics with people with harmless moles, delaying the treatment of malignant lesions.

Drummed into them

Anxieties about cot death and melanoma, both relatively rare conditions, must now vie for attention with the established health panics of recent years. Everybody has already had it drummed into them that smoking cigarettes, drinking alcohol, eating rich food and not taking enough exercise are at the root of the 'epidemics' of cancer and heart disease that are said to be the main causes of death in our society. The greatest panic of all, of course, surrounds Aids, widely regarded as the ultimate penalty for sexual licence or drug abuse.

Redefining disease

This medicalisation of life and its problems involves two inter-related processes. On the one hand, there is a tendency to expand the definition of disease to include a wide range of social and biological phenomena. Thus, for example, while the inclusion of crime within the medical framework remains controversial, the excessive consumption of alcohol or use of illicit drugs are widely accepted as medical problems. So too is obesity, a biological variant which is acknowledged as a disease state; by American National Institutes of Health criteria some two thirds of adult males are affected. According to some criteria around one third of the British population suffer from a raised cholesterol level. In a similar way, substantial proportions of the population are arbitrarily designated as having a high blood pressure.

On the other hand, people suffering from this expanded range of disease states are increasingly evaluated in psychological or moral terms. Now that the causes of the old infectious diseases have largely been discovered and effective treatments developed, they have lost their menace and their mystery. By contrast, the causes of the modern epidemics remain obscure and effective cures elusive. Today there is a tendency to believe that people become ill because they want to (as for example in the view that cancer results from 'stress' or depression) or because they deserve to (because they smoke or drink too much).

While people who succumb to viruses or bacteria are generally regarded as unfortunate and worthy of sympathy, those who get cancer or heart disease are, at least to a degree, held up to blame for their unhealthy lifestyle. Because of its major modes of transmission in Britain - through sex, particularly gay sex, and drug abuse - HIV infection, though a virus, is ideally suited to the prevailing discourse of individual moral culpability.

Gluttony and sloth

If disease is the wages of sin in modern Britain, medicine has become a quasi-religious crusade against those old sins of the flesh - gluttony, sloth and concupiscence. The trend for religion to give way to science and for the scientist to take over the social role of the priest has been a feature of modern society since the Enlightenment and the French Revolution. The success of scientific medicine in the twentieth century has particularly enhanced the social prestige of the medical profession. Yet it seems that the final triumph of doctors as guardians of public morality comes at a time when they are generally incapable of explaining or curing the major contemporary causes of death and disease. Let's look more closely at the cult of health promotion.

Critics of health promotion have exposed a number of irrational features common to many popular health campaigns. The first is what Petr Skrabanek and James McCormick call the 'fallacy of cheating death' (P Skrabanek and J McCormick, Follies and Fallacies in Medicine). Much of the difficulty in both understanding and treating most forms of cancer and heart disease is that they are closely related to the ageing process. In a society in which many more people escape an early death from infectious diseases, they finally die in old age from a tumour, a heart attack or a stroke. Though some younger people also suffer premature death from these causes, the notion of 'epidemics' of these diseases rests on the inclusion of the deaths of vast numbers of old people.

The grim reaper rules

Yet, given existing levels of scientific knowledge, there is still no escaping the grim reaper. The idea that preventing cancer and heart disease could usefully prolong life is based on the illusion of defying mortality. It has been estimated that the gain in average life span resulting from the elimination of cancer deaths between the ages of 15 and 65 would be seven months (Follies and Fallicies in Medicine, p89). Furthermore, given the expanding population suffering various forms of another untreatable condition associated with ageing - senile dementia - it is clear that the postponement of death does not necessarily mean the prolongation of a healthy life.

A second area of irrationality surrounds the role of 'risk factors' in the causation and prevention of modern epidemic diseases. The speciality of epidemiology, which arose as the study of the mode of spread of infectious diseases, has become concerned with identifying statistical associations between various factors and the incidence of cancer and heart disease. But, contrary to popular assumptions encouraged by the health promotion industry, an association is not the same as a cause, and modifying risk factors cannot be presumed to reduce the incidence of a related disease.

Passive smoking scare

Skrabanek has noted that some 246 risk factors have been identified in relation to coronary heart disease; he argues persuasively for the use of the term 'risk marker' rather than risk factor ('Risk factor epidemiology: science or non-science?', in Health, Lifestyle and Environment: Countering the Panic).

Health propagandists confuse relative risk, which measures the strength of the association between a particular exposure factor and a disease, and exposure or absolute risk, which measures the actual harmful effect of a factor, the risk of dying from a disease solely because of exposure:

'A factor can be very strongly associated with a particular disease, so that almost all cases of the disease are due to the factor and the relative risk is very high, but still have only a small effect because the disease is rare even among those exposed to the factor.' (P Finch, 'Creative statistics', in Health, Lifestyle and Environment, p80.)

The classic example of this statistical scam is the scare about 'passive smoking'. Though it is often said that the relative risk of non-smoking wives of smokers getting lung cancer is 30 per cent increased, it is rarely stated that their exposure risk is one in 50 000.

A third problem follows from the identification of risk factors: the notion that screening for such risk factors in a healthy population helps to prevent disease and allow early diagnosis and treatment of pre-morbid or pre-malignant conditions. Skrabanek and McCormick argue that the old adage 'prevention is better than cure' is only true if the disease in question is common, serious and treatable. If it is relatively uncommon, such as for example, breast or cervical cancer, then even a good screening test will inevitably yield a high rate of 'false positives', people wrongly diagnosed as having the condition.

Smear stories

In fact, the available screening tests of mammograms and smears have a low predictive value. In the case of mammograms this leads to a high rate of overdiagnosis of tumours leading to unnecessary biopsies. Smears carry the additional defect of a high rate of false negatives - they miss women with malignant changes - as well as throwing up diverse 'abnormalities' of uncertain significance. These lead to numerous 'repeat smears', with follow-up colposcopy and cone biopsy in cases of continuing uncertainty.

It is likely that in 70 per cent of the 100 000 women diagnosed every year as having a seriously abnormal smear and treated accordingly, the abnormalities would regress spontaneously. 'Better safe than sorry' chorus the health promoters, but they do not generally have to endure procedures that are at best unpleasant and uncomfortable, involving time-consuming clinic appointments, with all the attendant anxieties of waits and delays; at worst they are invasive and traumatic.

Furthermore, there is little evidence to substantiate the widespread presumption that early diagnosis leads to a better prognosis. After years of experimentation with surgery, radiotherapy and chemotherapy regimes in the treatment of breast cancer, there is little consensus that any substantially improves long-term outcome. The death rate from cervical cancer has remained constant over the past decade despite the fact that enough smears have been performed to screen the female population twice over.

The ultimate confirmation of the irrationality of health promotion is its immunity to refutation by facts. The classic illustration of this is the persistence of the promotion of a 'healthy diet' on the grounds that it prevents coronary heart disease. The diet-heart disease thesis rests on the notion that, if a high-fat diet contributes to the build up of those fatty plaques inside the coronary and other arteries that lead to heart attacks and other manifestations of atherosclerosis, then a low-fat diet will reverse these pathological processes and reduce the resulting morbidity and mortality. This is a plausible thesis, but despite decades of intensive study, it lacks scientific verification.

Eat your heart out

Critical evaluation of large population surveys, and particularly controversial cross-cultural and migrant studies, reveals ambiguous results which fail to demonstrate that dietary modification can prevent coronary heart disease (see J Le Fanu, Eat your Heart Out, and TJ Moore, Heart Failure). Le Fanu alleges that 'those responsible for promoting the diet-heart disease theory seem to me to have deliberately edited or censored evidence to justify their case' ('A healthy diet - fact or fashion', in Health, Lifestyle and Environment', p102).

A recent sequence of events reveals a now familiar process. In February the British Medical Journal reported the results of a major trial on the prevention of coronary heart disease by reducing cholesterol levels (by advice about diet, smoking and exercise, and drug treatment for raised blood pressure and cholesterol) (BMJ, 15 February). The survey revealed that over the 10 years after the end of the trial, cardiac deaths and total mortality increased among those who received medical intervention compared with those who did not. Another report noted an increase in non-cardiac deaths related to drug treatment for raised cholesterol levels.

Spanner in the works

A lead editorial in the same issue conceded that these results had 'thrown a spanner in the works of those concerned with prevention' ('Doubts about preventing coronary heart disease: Multiple interventions in middle-aged men may do more harm than good'). It concluded that the results 'should make doctors, health educationalists, managers and politicians reconsider the value of current policies for the primary prevention of coronary heart disease'.

Six months later the government obstinately declared that 'plasma cholesterol is the most important risk factor for coronary heart disease' and claimed that 'a reduction of 10 per cent in the average plasma cholesterol level might result in a 20-30 per cent reduction in CHD deaths' (The Health of the Nation: A Summary, p14). It proceeded to set 'targets' for reducing the proportion of fat in the national diet.

The conviction that reducing dietary fat prevents heart disease has all the strength of a prejudice which cannot be shaken by any number of contradictory scientific studies. Indeed the prejudice in favour of a low-fat, high-fibre diet today is no doubt as strong as the conviction a generation ago that dairy products and red meat were essential to a healthy diet.

Exercising faith

Two contributors to the BMJ debate on the initial Health of the Nation green paper, which was published in June 1991, reveal the anti-scientific mentality of the health promotion lobby. In their advocacy of 'the role of exercise', Henry Dargie and S Grant take on the sceptics:

'Some would argue that there is no conclusive evidence from controlled trials that regular exercise reduces the number of deaths from coronary heart disease or substantially prolongs life. To demand such proof is to miss the point about exercise, which is that it is valuable for numerous other health benefits it confers and as a catalyst in the adoption of a healthier lifestyle.' (The Health of the Nation: The BMJ View, p156)

Given that a major national effort is invested in promoting exercise on the grounds that it prevents heart disease, it seems fair enough to ask for some evidence to substantiate this claim. Yet our doughty exercise enthusiasts duck this demand, countering with an assurance that it confers numerous other health benefits. No doubt to request evidence for these benefits would also be to miss the point, which is that the health promoters firmly believe that exercise is conducive to a healthier lifestyle. It is faith not science that justifies exhortations to change public behaviour.

Evangelical zeal

It may seem churlish to criticise a campaign to encourage people to take more exercise - something that many would say is obviously beneficial. But the same cannot be said for many other health campaigns which are promoted with the same evangelical zeal and received with the same remarkable lack of public scepticism, as one American observer has noted:

'What I find very intriguing as a sociologist is that many people who would not believe a word said, for example, by the US Secretary of Defense, take as gospel truth what is pronounced by the Secretary of Health and Human Services. This is not a rational response to a body of evidence. It is an act of faith.' (P Berger, 'Towards a religion of health activism', Health, Lifestyle and Environment, p27)

The cult of routine health checks is 'uncovering' - or creating - a wave of newly labelled sufferers from high blood pressure, obesity and raised cholesterol levels; screening inflates the incidence of various forms of cancer. These campaigns, together with each new media health scare, create a climate of pathological preoccupation with health, making disease the focus of much anxiety and depression.

Libertarian backlash

It is striking that virtually all of the criticisms of health promotion come from the political right. Many of the authorities I have quoted above contributed to a symposium on the new public health held jointly by two right-wing think-tanks in the USA in 1991 (Health, Lifestyle and Environment: Countering the Panic, Social Affairs Unit/Manhattan Institute, 1991). The right-wing critics of health promotion represent a free-market, libertarian backlash against both Labourist and traditional conservative welfare paternalism - 'nannyism' - in the health sphere. Occasionally intemperate in tone, they polemicise against enemies such as 'consumer socialism' and 'food Leninism'.

One common theme among contributors was the condemnation of health promotion as 'the new activism of the new class', a vaguely defined sociological category apparently made up of radical public sector professionals who have carried their anti-establishment and anti-scientific prejudices with them on the 'long march through the institutions' from the youth culture of the sixties. Though most contributors welcomed the tendency to blame individuals for disease, they emphasised what they considered the dominant tendency of blaming corporations, producers and advertisers, for encouraging unhealthy behaviour and creating an unhealthy environment.

While it is no doubt true that many veterans of the sixties now play a prominent role in health promotion, it is the Conservative government, with the support of the medical profession, that has dictated the terms of official health promotion. Just as it seems unlikely that the direction of the Thatcher government's Aids campaign was decided by the Terrence Higgins Trust, so the preventive zeal of the Major government is unlikely to have been influenced by the radical doctors behind the Healthy Eastenders Project.

Fearful age

It is clear that the government itself has taken up the issue of health as a convenient vehicle for promoting its gospel of conventional morality and individual responsibility. This is a particularly useful project for the Tories at a time when deepening recession threatens to undermine social cohesion still further, and when the insecurity of everyday life makes many people vulnerable to panics about personal health. The Health of the Nation report, with its curious synthesis of old-fashioned state socialist paternalism, Stalinist planning 'targets' and Thatcherite moralistic finger-wagging, is a document designed to exploit the mood of our fearful age.

One of the few commentators on the moralising of disease from a liberal rationalist viewpoint is the American writer and critic Susan Sontag. In Illness as Metaphor, published in 1978 following her personal experience of cancer, she discusses the way in which the myth of individual responsibility has shifted in modern times from tuberculosis to cancer. In her 1989 sequel, Aids and its Metaphors, she notes that the main theme in the response to Aids in the USA is the backlash against the 'permissiveness' of the sixties: 'fear of sexuality is the new, disease-sponsored register of the universe of fear in which everyone now lives'. She regrets the impact of the Aids panic in reinforcing moralistic attitudes towards sex in America and the wider culture of individualism.

'Don't let yourself go'

Sontag looks further at the question of why the Aids panic has had such a resonance in modern America. She notes the popularity of apocalyptic scenarios such as nuclear holocaust and ecological catastrophe, reflecting a sense of cultural distress and of society reaching an end: 'There is a broad tendency in our culture, an end-of-an-era feeling, that Aids is reinforcing; an exhaustion for many of purely secular ideals.'

While people with Aids adopted programmes of self-management and self-discipline, diet and exercise, Sontag saw the wider Aids panic connecting with a public mood of restraint, 'a positive desire for stricter limits on the conduct of personal life', encouraging attitudes such as 'watch your appetites, take care of yourself, don't let yourself go'. The prevailing climate of impending doom provides ideal conditions for health scares.

At a time when medical advice has become so confused with moral sermonising, and when social insecurities provide plenty of scope for scaremongering, what is the sensible approach to health promotion and disease prevention?

Social solutions

The most effective methods of prevention are those, such as improvements in sanitation, housing and living standards, which are undertaken collectively in society and do not require changes in individual behaviour. Some behaviour changes - such as wearing seat belts or crash helmets or getting babies immunised - rely upon social consensus. More deeply rooted patterns of behaviour, such as smoking, are unlikely to be changed by individual exhortation.

The excess morbidity and mortality of working class people cannot be understood as the result of a range of unhealthy behaviours requiring individual modification. It is the totality of the experience of the working class in capitalist society that causes its ill health - and this can only be tackled collectively, as part of the much wider problem of the way society is organised.

Stop preaching

The World Health Organisation's definition of health as 'a state of complete physical, mental and social well-being' is absurd: this is a utopian ideal not a practicable policy goal. While health is being expanded into the sphere of politics, medicine is being corrupted by morality. What is required is the redrawing of appropriate spheres of influence.

The problems of society require solutions at the political level which cannot be achieved by exhortations to change individual behaviour. Doctors should stop preaching and get back to treating patients suffering from diseases, recalling the wise words of HL Mencken:

'The aim of medicine is surely not to make men virtuous; it is to safeguard them and rescue them from the consequences of their vices. The true physician does not preach repentance; he offers absolution.' (Quoted in Follies and Fallacies in Medicine, p139)
Reproduced from Living Marxism issue 47, September 1992

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