I spent this Christmas, as I’m sure many others did, over-indulging in rich foods and alcohol, and barely moving from the sofa. I made choices that were far from healthy, and take full responsibility for the resulting lethargy, bad skin and headache.
But on a larger scale, to what degree is an individual responsible for their health? It is all too easy to label the smoker with lung cancer, the alcoholic with liver failure or the obese patient with heart disease as culpable and look no further. And of course it is true that no-one held a gun to their head and made them smoke, drink, or eat to excess. But this view is dangerously narrow and simplistic. The actions of individuals and their health-related actions must be viewed within a broader social context. We act as individuals but we do not live in a vacuum.
There is a huge body of literature on the social determinants of health, encompassing the effects of the physical, social and cultural environment. To hold people responsible they must have true choice and control. But to what degree does an individual make a true choice, influenced as they are by their sex, race, socioeconomic status, education level, peer group, and cultural identity in addition to being bombarded by manipulative and exploitative advertising? Focusing too strongly on individual responsibility in relation to health is particularly unfair in relation to poverty. Poverty itself has a negative impact on health, even when individual factors such as smoking and poor diet are controlled for. It is no longer a radical concept that people at progressively lower socioeconomic status levels have correspondingly less opportunity to control the circumstances and events that affect their lives, and that control is imperative to well-being.
Class as a factor must not be ignored. Not only does class have a huge impact on an individual’s beliefs and expectations of health, but the debate on personal vs societal responsibility for health is often conducted in a class-influenced framework. Most of the discussion is led by the privileged middle-classes – politicians, academics and physicians who are wealthy, highly educated, with the freedom to consume and act on the information on “healthful choices.” Those that are castigated for making “poor choices” in relation to their health are often the working class; seen as stubborn, short-sighted and a drain on the country’s constrained health resources.
Putting politics and morality aside, on a practical note, to make real population changes a population approach is required. A huge burden of disease can be directly attributed to a combination of smoking, obesity and a lack of exercise. This costs, and will continue to cost the country vast sums in healthcare, social care and lost work days. As a public health strategy, targeting individuals to take more responsibility is unlikely to have a significant impact on these large-scale health problems. Society-wide initiatives work – banning smoking in public places has had a much greater impact on quit rates than years of poster campaigns and a “nudge” approach.
We need healthy public policies and health-promoting environments, that support individuals in making choices conducive to good health. We can still safeguard autonomy and acknowledge that different individuals within the same context make different decisions. But we must avoid victim-blaming, which helps no-one.