The Regulation Of Lifestyle

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Everybody should try to look to after themselves better, by not smoking, taking more exercise, eating and drinking sensibly.

(Saving Lives: Our Healthier Nation, White Paper on public health, July 1999, vii)

While clinical trials have shown the benefits of stopping cigarette smoking, many of the changes in lifestyle that are being promoted by Western governments are based on information lacking in solid evidence. It is unpardonable to try to alter the diet of an entire population without sufficient information.

(David Weatherall, Science and the Quiet Art, 1995:311)

Nor can very much be changed by the trendy fashions in changing 'life-styles', all the magazine articles to the contrary; dieting, jogging, and thinking different thoughts may make us feel better while we are in good health, but they will not change the incidence or outcome of most of our real calamities.

(Lewis Thomas, The Fragile Species, 1992:14-15)

David Weatherall, currently director of the Institute of Molecular Medicine at Oxford, and formerly Nuffield professor of clinical medicine at Oxford, is one of Britain's leading clinical scientists; Lewis Thomas, professor of paediatrics, pathology, medicine and biology and dean of two medical schools, enjoys a similar status in the USA. The discreet scepticism of these two eminent medical authorities regarding the central themes of government public health policy on both sides of the Atlantic indicates two things: that some medical experts question the scientific basis of this policy— and that this questioning has had done little to deter the rise of public health promotion to become a major influence in modern society and in the everyday lives of its citizens.

The 'big four' injunctions of health promotion—to stop smoking cigarettes, to eat a healthy diet, to drink alcohol in moderation, and take regular exercise—have become firmly established in popular consciousness. People may not heed the advice coming at them from the government, the media, the medical profession, but nobody can now be unaware of the key components of what is officially regarded as a healthy life. The huddles of furtive smokers outside ordinary houses as well as public buildings symbolise the ascendancy of preoccupations about health over social behaviour.

Over the past decade the reach of health promotion has widened and deepened. Each of the big four has expanded and become more differentiated. The evils of smoking have been compounded by the perils of passive smoking. Every schoolchild knows how to calculate the units of alcohol in different beverages and the approved limits for men and women. The merits of fruit and fibre and the dangers of saturated fatty acids have been ventilated in every kitchen in the nation, just as almost every household has an exercise bike and an aerobic workout video (however rarely used). Everybody is also now aware of the dangers of exposure to sunlight, how to put a baby to sleep to reduce the risk of cot death and of the requirements of safe sex. Medical jurisdiction over lifestyle now extends into the home, the workplace, the school and the neighbourhood. It also covers every moment of the life-cycle, from pre-conception counselling, through pregnancy and childbirth, infancy, childhood and adolescence, not merely women's health but also men's health, the menopause (and the male mid-life crisis), old age and death.

In this chapter we look at the evolution of some of the key themes in the regulation of lifestyle in the cause of health. The origins of current health promotion policies lie in the responses of modern medicine to the challenges of coronary heart disease and cancer, conditions whose importance increased dramatically in the mid-twentieth century as the menace of infectious disease receded. The demonstration, in the early 1950s, of the link between cigarette smoking and lung cancer was the towering achievement of modern epidemiology, providing the rationale for a strategy of prevention which has been fervently sought in relation to other diseases. Unfortunately, though numerous risk factors have been identified, no distinct causal agent has been discovered for any other common form of cancer or for heart disease. As a result, preventive strategies have had to fall back on attempts either to modify risk factors or to detect disease at an early stage.

The assumptions that prevention is better than cure and that early diagnosis is preferable to late diagnosis have a ready appeal— for both doctors and patients. This guarantees widespread popularity for health promotion policies, especially when the condition in question is a common cause of death and disability. Yet these assumptions may not be correct. Both health promotion policies and screening programmes involve interventions in the lives of the mass of the well in the hope of preventing diseases among a few. These interventions may cause considerable adverse consequences for some of the well, while not even benefiting many of the few, some of whom still succumb to the disease.

Yet, though all forms of health promotion have provoked medical and scientific controversy over their claims to effectiveness, they have steadily gained in public prestige and impact over the past two decades. As a result, interventions which originated in the world of medicine have long since acquired a wider social and political significance, so that they can no longer be understood exclusively, or even primarily, in medical terms. In the following chapters, we will be looking at screening programmes and at the political controversies around health promotion; here we focus on the 'big four' lifestyle issues targeted by health promotion activists.

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