In Praise of Bad Habits – Part 2
ICR Lecture – November 17th 2001
The transformations in public health philosophy in revolutionary France were founded on the ideology that instruction in diet and lifestyle were the keys to ensuring the eventual compliance of the French people. It was, therefore, perhaps no accident that the head of the first ever government public health department in Europe, established in 1798 – the year of the Revolution itself – was none other than one Dr. Guillotin – more familiarly known as the inventor of an efficient decapitation device – the guillotine.
Commenting on this period of history Petr Skrabanek notes:
"It is a paradox that the Age of Enlightenment, which destroyed the false certainties of religious dogmas and freed man from superstition, forged, at the same time, new chains for the enslavement of man, by regarding him as a machine, governed by materialistic and deterministic laws."
Elsewhere in Europe in the 18th century other types of coercion in health policy were beginning to develop. In Germany for example, many medical journals included in their titles the term Medizinalpolizei,(medicine police), and later Gesundheits-Polizei (health police). The medical historian George Rosen has argued that the concept of medical police was part of a broader political force which sought to secure greater wealth for the merchant classes and the aristocracy by ensuring that workers were sufficiently fit for their semi-slave roles.
This trend, according to Paul Weindling at the Wellcome Unit for the History of Medicine led to more far-reaching consequences:
"Medicine was transformed from a free profession, as it was proclaimed by the German Confederation in 1869, to the doctor carrying out duties of State officials in the interests not of the individual patient but of society and future generations."
This convergence of state and medical interests was also reflected in Britain in the rise of the eugenics movement in the early 1900s, following publications by Francis Galton and others. The philosophy enshrined the belief that the quality of human stock could be improved, as in the case of other animals, by preventing the reproduction of those of lesser quality while encouraging propagation of the superior variety. The term 'social hygiene', which quickly followed the development of eugenic ideology, incorporated notions of genetic selection with concerns for sanitation, diet, personal lifestyle and child care. While previously ill-health had been seen as an unavoidable misfortune, it now became (at least in part) the result of bad habits.
The fact that such dangerous philosophies were seen as persuasive by health reformers was due in large part to the pressures to achieve 'national efficiency' prior to the First World War. From the point of view of Charity Commissioners and the medical profession, the number of 'undeserving' poor in society had become unacceptable and radical steps were needed to reduce such a burden in times of economic recession. The eugenic ideology, therefore, found favour across the political spectrum, with 'left', 'right' and 'new liberals' all in agreement that control of breeding and lifestyles was a legitimate role for the State.
These patterns of convergence of the state and medical professions were the direct precursors, according to some historians, for the ultimate expression of lifestyle and health prescription which lay at the heart of the philosophy of the Third Reich. And comparisons between contemporary healthism and that which developed in Germany in the 1930s are, I'm afraid, so striking that they cannot be ignored. The philosophy of Gesundheit ist Pflicht – health is duty – initially took on forms that are disconcertingly familiar in modern health trends.
The implications of such parallels have been highlighted by the New York professor of paediatrics, Hartmut Hanauske-Abel, who has provided us with some of the most cogent arguments against contemporary trends towards health 'intervention' in an article in the British Medical Journal in 1994 on German medicine and National Socialism in the 1930s. He had previously published a similar article in the Lancet in 1986 As a result, the German medical authorities withdrew his sub-licence to practice emergency medicine. It was only restored to him after a decision by the Supreme Court.
Hanauske-Abel is highly critical of his predecessors in Germany and of the active role they played in furthering the aims of the Third Reich. He argued that, far from German doctors being corrupted by Hitler's regime, they were ahead of the regime in advocating policies on eugenics. While this accounts for his lack of popularity among the German medical profession, his argument that what is happening in the profession today has many striking similarities with the early 1930s has resulted in even greater hostility.
His arguments are detailed and sometimes complex. But the core of his thesis, based primarily on analysis of documents published in 1933 in German medical journals, is to do with two types of convergence. The first of these is the one I have already noted between the state and the medical profession. Doctors were no longer in the business of diagnosing and treating ailments but of inculcating in their patients a narrow philosophy of health – what today we would benignly refer to as health promotion, but which has its roots in fundamentally illiberal and dangerously authoritarian political ideologies.
The second type of convergence with which Hanauske-Abel was concerned was that of political convergence – the virtual eradication of political opposition, resulting in a single area of consensus regarding all aspects of state control and intervention. I am not normally prone to alarmism – but, it seems to me that we now live in what might be described as a 'post-politics' decade. There is no real political debate in Britain, as we saw in the run-up to the last election – just an uncomfortable sharing of a right-leaning, centrist position. Even when thousands of tons of bombs rained down on what little was left of Afghanistan in the so-called 'War Against Terrorism', as we sought to oust one band of murdering thugs by arming and supporting an equally bloodthirsty band of zealots, voices of dissent amongst those claiming to be the people's representatives were so muted and faint that they were hardly audible. It is particularly in times of economic decline, as witnessed in 1930s Germany, that such forms of political convergence can have calamitous effects.
Hanauske-Abel concluded his BMJ article by saying:
"Contextual analysis of events during the summer of 1933 in Germany [The year Hitler rose to power] may not just improve an understanding of the past but may also help to assess the present and near future. Developments within medicine and society during the past decade, particularly in North America and Europe, may found another convergence of previously separate political, scientific and economic forces. These forces may not be as demoniacal as those in Germany in the summer of 1933, but only by approaching their next alignment with great caution can we avert a conflagration".
OK, this may sound rather over-dramatic – and that is what I felt when I first read the article. And I am certainly not suggesting that medics and health professionals are involved in a sinister neo-Nazi conspiracy. I am not saying that at all. But the more I examine the intolerance which our society extends to those it deems as exhibiting 'bad habits', the more I am reminded of those concepts of 'racial hygiene' 'health purity' and of the 'duty' to conform to the state's concept of 'healthy living' – it's an uncomfortable feeling. And it is this 'discomfort' with historical reminders that is evident in Germany today. It has been suggested, for example, by George Davey Smith – an epidemiologist at Bristol University – that one of the reasons many Germans continue to smoke cigarettes in apparent defiance of extensive anti-tobacco campaigns is because of reminders of the Nazi past. For Hitler, tobacco was a 'genetic poison' and the anti-smoking campaigns that he personally instigated were allied directly to the promotion of Aryan superiority. The stance taken by Goebbels on coffee was very similar. And the memory of these lingers on.
Patterns of convergence similar to those occurring in 1930s Germany are also evident in the role of supra-governmental groups such as the World health Organisation, which force quite narrow Western concepts of health into the agendas of developing countries – hence seat-belt wearing campaigns in Mozambique where the main form of transport is the water buffalo and cart. And Deborah Lupton again notes that under the prevailing discourse of 'healthism', the pursuit of health has become an end in itself rather than the means to an end. For the WHO, health has become reified to the extent that it is defined by them as 'a state of complete physical, mental and social well-being' – a phrase which, given the points I have just raised might be seen as having sinister overtones. As David Seedhouse, Director of the National Centre for Health and Social Ethics in New Zealand has noted:
" … in pluralistic societies any claim to know objectively the constituents of a worthwhile life must at the very least be treated with caution."
Seedhouse argues that the whole notion of 'well-being' should be dropped from the WHO mandate. Not only is the concept too vague to be used as a measure of the effectiveness of health promotion, it smacks very strongly of the 'we know what is best for you' philosophy. Robert Downie and his colleagues, in one of the 'bibles' of health promotion used by WHO activists, show that they are clearly exponents of this paternalistic role. They note that 'well-being' can be viewed in one sense as a subjective judgement made by individuals about their own physical and mental states. Ordinary mortals, however, as opposed to health promoters, may have 'illusions' about their own well-being – they are not 'feeling great' at all. They say:
"Subjective well-being … may be spurious and may arise from influences which are detrimental to an individual's functioning or flourishing and/or to society."
From this standpoint, the large lady in Polynesia, who is culturally valued because of her size and weight, and lives a contented and long life as a result, is deluded. Her Body Mass Index (BMI) of over 30 is contrary to the WHO's 'objective' measure of well-being – she is 'obese'. She must, therefore, be 'encouraged' to become a more 'normal' size despite the fact that this will inevitably make her less culturally valued, and probably quite miserable. There is also no real evidence that she will live any longer either.
For Seedhouse and others, the concept of 'objective' well-being, which is at the core of the WHO philosophy, consists of nothing more than unfounded prejudice. It provides a 'cover' for health promoters whose real " … intentions and preferences", he suggests, " are becoming too obvious."