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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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