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Saturday, 20 April 2013

Health inequality and personal responsibility

A discussion on Radio 4's Today program earlier in the week really caught my attention. I've been thinking about it on and off ever since.

The discussion surrounded public health inequalities. It was being considered in the context of the recent devolution of responsibility for public health to local authorities. A specific issue mentioned was heart disease, and the factors leading to heart disease. The contention is that heart disease is, broadly speaking, a lifestyle illness. That is to say that lifestyle factors such as poor diet, not taking enough exercise, smoking and drinking alcohol all make heart disease - a long with a host of other diseases - more common.

All of these things - poor diet, not taking enough exercise, smoking and drinking alcohol - correlate with having a lower income.

So why do poorer people take less care of themselves?

Do they simply not have enough money to make healthy choices?
Are healthy choices inaccessible for other reasons (eg no shops selling healthy foods)?
Are they not educated enough to know what is healthy?

I don't find these arguments convincing. Money can be an issue, but budgeting makes healthy eating much cheaper than takeaways. What's more, if money was the key issue surely smoking and drinking alcohol (non-essentials!) would disappear? This is an issue of prioritising spending.

I accept there may be a few small communities where the only food sold is from the local chippy (or similar), but I don't think there can be many of them. As we keep hearing, Tesco (or her competitors) is everywhere. And Tesco sells healthy options.

While there may be some confusion about the finer details of a healthy diet, I think we've all got the key messages: smoking, alcohol, high fat/sugar/processed foods = bad. Everyone knows what we mean by '5 a day'. Everyone knows regular exercise is good for you.

The reasons above call for intervention. The state should intervene to ensure people have a minimum income (which will magically make people more responsible with their choices).

Now, to Conservatives like me - liberal Tories - this just does not sit right at all. Especially when accompanied by quotes like this:

"And if people’s jobs are less stable, they may be forced to change their diet, or drink and smoke more." [emphasis added] - Dr Perviz Asaria, quoted here on heart disease.

Which to me, is just plain ridiculous.

These paternalistic attitudes are dis-empowering and strip people of personal responsibility. This is not helping people. The reason poorer people eat poorer diets, exercise less, smoke more and drink more alcohol is because they choose to do so. People are, or should be, responsible for their own choices. Taking out personal responsibility in this way is making healthy choices even less likely to be made.

On its own, this may seem overly simplistic. I accept that various factors (income, education, culture) may make it harder to make healthy choices. What I do not accept is that any of these things make healthy choices impossible, or unhealthy choices inevitable or forced.

If we are to tackle public health issues like this we must move responsibility downwards to the individual. Devolution of public health to local authorities is a welcome step. Not least because it means the variety of approaches will allow us to evaluate more and less successful methods.

I think it is time to consider the ways in which the NHS, as free and without judgement, is possibly contributing to these lifestyle illnesses. Does the sense of security created by the NHS make people less concerned about taking care of their own health, and preventing illness? Does medication to treat the early ill-effects of lifestyle disease lead to complacency from the individual? How can we introduce enough personal responsibility in to healthcare provision to mitigate these effects, without leaving people to suffer?

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