Why 'health' is not fit for purpose - opinion - 22 November 2010 - New Scientist

How can you be against health? (Image: Iechine/Flickr/Getty)

The idea of health has become too much of a sacred cow to challenge. Time to slaughter the beast, say Jonathan M. Metzl and Anna Kirkland

WHY would anyone in their right mind be "against health"? Surely the only position possible must be "for" health?

Not if you talk to a growing band of dissenting academics in disciplines ranging from history and literature to medicine and law. In a new book, entitled Against Health: How Health Became the New Morality, we've tried to capture some of the flavour of this critique.

The basic argument is that the time has come to stand against health as currently understood. Health now means more than the absence of disease or presence of a positive state of bodily flourishing. In 2010, health also describes an ideological and commercial tool, used to make moral judgements, convey prejudice, sell products, or even to exclude groups of people from healthcare. The near-sacred status of the word has protected it from criticism for too long.

We should stress here that the authors in our volume have absolutely nothing against penicillin, the germ theory of infectious illness, stem cell research, bike helmets, sunscreen, enteric-coated tablets, or a host of other advances. The objections are to the ways in which the rhetoric of health is being used to promote value judgements, hierarchies, and blind assumptions that speak as much about power and privilege as they do about well-being. This has become frustratingly clear in the US political arena, where battles over healthcare plans thinly veil divergent assumptions about health, responsibility, and what it is to be a person.

The ideological and moral functions of health also percolate down to the individual level. So when we see someone smoking, we might say: "Smoking is bad for your health," but mean: "You are a bad person because you smoke." Equally, with someone whose body size is deemed excessive, we say: "Obesity is bad for your health," when we mean: "We can't hire someone who looks like you."

We are not the first to attack the notion of health. In the 1970s and 1980s, Austrian philosopher Ivan Illich famously delivered a series of lectures entitled "To Hell With Health", in which he bemoaned the negative effects of excessive preoccupation with health and the US industries that gained financially from promoting it. Health, he reportedly said, "is the most cherished and destructive certitude of the modern world. It is a most destructive addiction".

Thirty years on, the powerful forces controlling the health business are stronger than ever. From inventing and selling new diseases to the endorsement of narrow medical specialisms, western society - especially the US - is thoroughly medicalised.

The powerful forces controlling the health business are stronger than ever

At the same time, despite the promise of President Barack Obama's reforms, average Americans must manage health risks on an individual level without much of a collective safety net. The expectation is that we will insure our own retirement through market investments earned through work (rather than relying on social security), receive health insurance as part of our employment package, and take personal responsibility for our health through diet, exercise, stress reduction, and keeping watch over ourselves, our children, and our ageing parents.

One of the many ironies is that at an individual level a health imperative reinforces the presumption of personal control deeply at odds with the reality of life. Cancer, accidents, Alzheimer's disease still strike those who do everything that they are told might save them.

The illusion of total self-care and independence inflates the sense of entitlement of those who think they have achieved it, putting unbearable stress on those who can barely achieve it, and conferring second-class citizenship on those who cannot achieve it at all.

At this point some people may feel like arguing that health is about empirical facts, that we are just social scientists making a fuss and that we should shut up and check out the scientific literature.

These would be cheap shots. We are in the tough position of understanding scientific knowledge and morality as deeply interwoven and also as deeply human constructions, while also acknowledging them to be indispensable in the modern world. So our book is not just "against" many of the current meanings of health, but "for" encouraging better conversations in our interactions with medical professionals - both intellectually and in our daily lives.

Suppose a patient is discussing test results that show borderline abnormality in bone density, cholesterol, or blood pressure. The usual presumption is that the test has detected some objective feature of the patient's body we can treat, just as if she or he had a burn or a broken bone. Perhaps there would be more tests, some drugs, and eventually a label, such as "osteopenia" or "pre-diabetes".

Shared scepticism between doctor and the patient could be helpful in removing some of the mystery from what is bound to be a stressful encounter. What did the test really measure? Would the treatment regime require giving up something pleasurable or convenient, and if so, what would all the pros and cons look like?

Bringing these questions into the discussion would mean the measure of health (the test) had been "denaturalised" - that it would no longer be taken for granted and instead become something that could be critically examined. That way, alternative notions of life and health would have entered the conversation.

This can only be a good thing. A process which allows the many, disparate meanings of "health" to be articulated and challenged is more likely to lead to deeper, more productive, and healthier interactions about our bodies, our politics and our desires.

Jonathan M. Metzl is a psychiatrist

Anna Kirkland is a political scientist and lawyer. Both are in the women's studies department of the University of Michigan. Against Health: How Health Became the New Morality is published this month (New York University Press)

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