Healthy lifestyles: The antecedents

In the 1970s, public health policies began to promote the idea that individuals are responsible for their health and therefore have an obligation to adopt healthy lifestyles. Over the ensuing decades, health became both an extremely popular topic for media coverage and a lucrative market for vendors of health-related products and services. What followed was a substantial increase in health consciousness and greater anxiety about all things that concern the body.

Do healthy lifestyles actually produce better health? That they should may seem like common sense, which is one reason it’s been so easy to promote the idea that they do. The question is difficult to answer with absolute certainty, however. For one thing, the behavior that counts towards a healthy lifestyle does not readily lend itself to the objective measurements required for reliable scientific evidence. Defining health is also tricky. Lifespan is often used to compare the ‘health’ of different nations, but this fails to capture the subjective sense of health that is meaningful to individuals. Perhaps most important, while in theory a healthy lifestyle might improve health, that does little good if – as is now obvious – it’s extremely difficult to maintain behaviors that require things like changing what we eat and how often we exercise.

A related question would be: Did the promotion of healthy lifestyles reduce health care costs? This too seems like a sensible assumption, and the assertion is quite popular, especially among politicians. Health care costs have increased to hand-wringing levels. Promoting healthy lifestyles costs governments next to nothing, while the cost of health care is all too easily quantified.

A review (by the Centers for Disease Control) of over 3,200 scientific articles on the health effectiveness and cost-effectiveness of disease prevention found only five examples where prevention led to cost savings (this was in 1993). They were all in the area of immunization and prenatal care. This counts as prevention, certainly, but it’s not the diet/exercise/smoking advice we typically think of when we hear the words ‘healthy lifestyle.’ Given prevailing health trends over the last few decades, it’s now apparent that the extensive promotion of healthy lifestyles has done little to prevent the expensive health consequences of such things as excessive weight gain and diabetes.

Other opinions on the question of cost effectiveness (admittedly not backed by scientific evidence) include those of Dr. Arthur J. Barsky and Robert Crawford. Barsky argues that the more we pay attention to the body (a natural consequence of increased health consciousness) the more likely we are to identify symptoms we regard as unhealthy. This in turn leads us to seek more medical care. So healthy lifestyles may make us feel less healthy, and for this we pay more.

Cultural historian Crawford contends that the promotion of individual responsibility — for health, in particular, but for other aspects of our lives as well — allowed neoliberals to privatize all too many aspects of our economy. Now that we’ve suffered the consequences of neoliberalism, we know that it increases both inequality and costs. Inequality decreases population health, and the increased costs of privatization include the costs of health care. An appreciation of the adverse consequences of privatization motivated opponents of the Health and Social Care Act 2012 in Great Britain.

Healthy lifestyles: Why now?

Although the desire to maintain health and recover from illness is certainly nothing new historically, there was something distinctly different about the promotion of healthy lifestyles starting in the 1970s. Why did this happen when it did?

The 1970s saw greatly increased concern about the costs of health care. In response, a new perspective on health appeared, as seen in policy documents such as the Canadian Lalonde report. What was new about this perspective was the idea that health policy should address issues outside the scope of the health care industry, including determinants of health such as the physical environment and the workplace. Health care had become nearly universal and yet it was still inadequate to address health needs, especially chronic conditions. It had also failed to address health inequalities. The new goal was to find better ways to improve health.

If this new perspective had been implemented as it was originally intended in the Lalonde report, there might very well have been improvements in population health. When economic and political interests chose to limit their support to the promotion of healthy lifestyles, an opportunity was lost.

In this post and the next I discuss some of the historical background that led up to the Lalonde report and the subsequent promotion of healthy lifestyles. For both information and insight, I am indebted to the book Why Are Some People Healthy and Others Not? When this book was published in 1994, the authors were disappointed that the new perspective had little impact on improving health. In a third post, I suggest that there are reasons to be more optimistic today.

The goal of universal health care

During the decades from 1920 to 1970, sickness insurance became increasingly available in industrialized democracies. There were several reasons for this. Some people, of course, believed it was the right thing to do. That was not the primary motivation, however. Wars, such as WW I, had a way of making governments aware of how desirable it was to have healthy young men.

There was also a widespread, optimistic belief that scientific medicine would change the incidence and treatment of common diseases. Even before sulfa drugs and penicillin produced dramatic results for infectious diseases, there had been considerable success in reducing infant and child mortality. This was most likely due to improved hygiene, not advancements in medicine. That wasn’t perfectly clear at the time, however, and public esteem for the medical profession increased.

WW II was yet another opportunity for governments to reflect on the health of citizens. The war also provided a huge dose of experience for young doctors practicing battlefield medicine. After the war, the shared experience of having fought and defeated an enemy contributed to the sense of community that made welfare programs possible. In Britain, plans for universal coverage had already begun to take shape in 1941.

Prior to the 1970s, increased spending on access to health care was considered social progress. (This was true even in the United States, which is now the only advanced country that still does not have universal health care.) Concerns about costs were offset by the widespread optimism that medical care would provide great benefits. The expansion of medicine was encouraged and welcomed. This benevolent attitude ended abruptly with the economic reversals of the 1970s (the oil crisis, unemployment, inflation).

The need to control costs

In the 1970s, government priorities changed from the desire to make health care more accessible to the need to control its escalating costs. It turned out to be much harder to contract the growth of health care than it had been to expand it. The medical industry seemed quite capable of expanding indefinitely, and it continued to do so.

As health care consumed a larger percentage of what governments were willing to spend, there was less money available for other public goods that influence the health and well being of a nation: safer roads, a cleaner environment, education, even an adequate police force. This was a serious problem.

It was the expansion of health care availability that had created a growing demand for more health care in the first place. This demand was not going to go away. (Promising less is never a popular political position.) Those who sought to restrain health care costs were up against popular new health care systems (Britain’s NHS, Canada’s provincially based medicare system, Medicare in the US). These opposing forces – a growing demand and the need to control costs – created a conflict, a dynamic that continues to this day.

A willingness to consider something new

By the 1970s it was apparent that the attempt to provide universal access had not eliminated health inequalities and inadequacies, but there was also something else going on — a decline in the medical profession’s public esteem. In part, this was related to disappointment in medicine’s progress: it proved much more difficult to prevent or cure chronic diseases than to eliminate infectious ones. But the decline was also part of a critical attitude towards a profession now seen as too powerful. According to some critics, the doctor (white/male) saw himself as God, and medicine had taken on a moral role previously reserved for religion.

The less optimistic attitude towards medicine’s future, the failure of increased health care access to make everyone healthy, and hostile criticism of a powerful medical profession created a climate in which new ideas — outside-the-box thinking – were welcomed, at least in some quarters. If medical science was not going to cure cancer, prevent heart attacks, or reduce the incidence of diabetes any time soon, what else might help? Were there things that could be done outside the sphere of costly biomedicine that would enhance health?

There were obstacles to pursuing a new path. The demand for more health care in a time of spiraling costs had a way of directing all attention and policy funding towards the health care system itself. There were few resources available to develop health improvement programs outside the medical paradigm. And within the medical profession, there was little financial motivation (and thus little enthusiasm) for programs that were not already part of conventional medical care.

Despite the obstacles, some governments were willing to give new ideas a try. In particular, Canada produced a major health policy document: the innovative and influential Lalonde report.

Continued in the next post, where I discuss the Lalonde report and what followed the introduction of these new ideas.

References:

Callahan, Daniel, Promoting Healthy Behavior: How Much Freedom? Whose Responsibility? (2001)

Theodore R. Marmor, Morris L. Barer, Robert G. Evans (editors), Why Are Some People Healthy and Others Not?: The Determinants of Health of Populations (1994). See especially chapter 8, ‘The Determinants of a Population’s Health: What Can Be Done to Improve a Democratic Nation’s Health Status?’, by Theodore R. Marmor, Morris L. Barer, and Robert G. Evans.