Like millions of other people, I put a fair amount of effort into “being healthy.” I don’t smoke, try to eat a reasonable diet, and so forth. I do all of this with the backing of a strong scientific consensus that such behaviors are likely to be very good for my health and longevity. None of this makes me special in any way; I am trying to follow what one might call the medical truth of health.
What I want to suggest here is that there is a dark underside to all that healthy behavior. The underside is that the healthy behavior encourages the view that individuals are largely responsible for their own health outcomes, and that if people end up unhealthy or diseased, it’s their fault for not having engaged in sufficiently healthy behaviors. Call this a “social truth” of health. This social truth has real consequences. On the one hand, if individuals are to blame for their poor health, then they should bear a lot of the cost of their disease. After all, there is a sense in which they “chose” to be sick because of their unhealthy lifestyle. On the other hand, policies designed to create healthier environments or at reducing structural factors associated with poor health outcomes, like poverty, start to seem less important.
“Healthism,” as a prescient article from 1980 called it, has been a growing part of the American social landscape since the 1970’s, when jogging emerged as a fitness trend. The rise of healthism coincides with the rise of neoliberalism, a loosely-grouped set of policies that aim at analyzing all parts of society in economic terms, expanding the reach of actual markets, encouraging competitive behavior between individuals, and encouraging people to view their lives in entrepreneurial terms (for example, treating education as an investment the value of which is measured in terms of its probable future returns in the form of higher income). Because of the focus on individuals and market behaviors, neoliberal governance tends not to see systemic or public problems except insofar as they can be reduced to the problems of individuals. Neoliberal thinking is so culturally embedded that we don’t realize how historically anomalous it is. Since the 1970’s, however, a number of trends exemplify its emergence. Examples include the deregulation of the finance industry, the decline of collective bargaining power by workers, the end of pension plans and their replacement by 401k and other market-based plans (where workers absorb the risk of a market crash), the rise of temporary employment and the “gig” economy, the decline in state support for universities (leading to higher tuitions and high levels of student debt), and so on. With the exception of the Medicaid expansion, even the Affordable Care Act (“Obamacare”) interpreted health in terms of access to insurance markets, and used government not to provision healthcare, but mostly to attempt to stabilize and regulate those markets.
It is in this context that we need to see our healthy lifestyles and the dilemma they pose. It is obvious that those who have the good fortune and the means can and should want to be healthy, for its own sake. On the other hand, the effort to be healthy directly feeds a narrative that says that poor health is the product of poor management, in the way that poor returns on financial investments might be. No one is ever simply “healthy;” even health today may hide illness to come, future illness that must be detected and prevented.
The problem is that the wellness narrative causes us to over-estimate the degree to which it is fair to blame individuals for their health outcomes. Consider cancer. Recent studies published in Science have found that a substantial percentage – perhaps as high as 65% – of the variation in cancer risk between different tissues can be explained by the number of stem cell replications in that tissue. More replications means more chances for mutation, which is to say that more replications means greater odds of “bad luck” striking. The studies are controversial, and certainly do not say, as was widely reported, that up to two-thirds of cancers are caused by bad luck. But they do at a minimum imply that cancer is not as preventable as we are often told.
Even if we take a relatively-uncontroversial thesis like the connection between smoking and lung cancer risk, it is still not clear how much smokers who get cancer should be blamed. After all, smokers are addicted to nicotine, an addiction that has been heavily encouraged by a legal industry with a history of hiding the health problems associated with its products. Thus, even if it is clear that there is blame to be assigned, it is not obvious that the individual is the right target. In cases where the causal factors of a cancer are more complicated, attempts to assign blame will be similarly more complicated.
Or, consider obesity. Should individuals be blamed for weight gain? Again, the case is not obvious, given that most of us live in areas where we depend upon cars to get around, have easy access to heavily-advertised, calorically-dense convenience foods, and have little time free from work either to cook or be physically active. Many Americans – particularly those of low income – live in so-called “food deserts,” where access to quality foods is difficult. There is good evidence that the salt, sugar and fat that find their way into convenience foods are highly addictive. The sort of healthy diet recommended by authors such as Micheal Pollan requires both a lot of money and a lot of time, something that most Americans lack.
None of this is to say that we should not try to be healthy. But it is to say that the neoliberal mindset abetted by healthism depends on a social truth about health that is, at best, a serious oversimplification. We need to learn to separate what is an individually-healthy behavior from good health policy, or we risk not only blaming people for what is not really their fault, but making it harder to craft policy with a better chance of making more people healthier.