In praise of bad habits

The dangers of 'healthism' - and the good thing about risk.

Dr Peter Marsh

Topics Politics

In the Western world we live in an age that is, by all objective criteria, the safest that our species has ever experienced in its evolution and its history. We are healthier than any of our predecessors have been. We live on average considerably longer than even our immediate progenitors. Today, the infant death rate is less than 6 per 1000 live births. Just 100 years ago the figure was 150. Even in the late 1950s four times as many children died in their first year of life than they do today.

Our diet, contrary to all the ‘anti-junk food propaganda’, is not only the most nutritious but also the most free from potentially dangerous contaminants and bacteria that we have ever consumed. Despite the class divisions which remain within our society, and which reflect themselves in the health gap between the rich and the poor, we have, as Harold Macmillan once famously said, ‘never had it so good’ when it comes to a lack of objective risks to our lives and to our wellbeing.

At the same time we have, ironically, come to fear the world around us as never before. In the absence of real risks, we invent new and often quite fanciful ones. The better off in our society, who have the least to really worry about, are most prone to this novel neurosis of our age – fearing instant death from the contents of their dinner plates, unless chosen with obsessive care, and ‘unacceptable’ physical decline from failure to follow every faddist trend recommended by their personal fitness trainers. We fear that our children are constantly in danger from strangers – despite the fact that the vast majority of child abuse occurs within the family – and feel compelled to ensure their safe arrival at school by transporting them in people carriers – while at the same time decrying the depletion of fossil fuels and ‘unacceptable’ levels of environmental pollution – and we wonder why our children are getting fat.

In this constant state of irrational fretfulness we start to lose our faith in anything that looks like science – preferring to put our faith in the ‘Emperor’s new clothes’ of homeopathic and other forms of complementary medicine, while withdrawing children from rational and safe vaccination programmes aimed at preventing an epidemic of measles following irresponsible scare-mongering in our newspapers.

Our flight from rationality is evidenced in other panics which currently preoccupy us. The development of biotechnology, for example, which holds real promise for the eradication of famine in much less fortunate parts of our planet, is resisted by the fit and well-fed for fear that we will release Frankenstein’s monster – despite the fact that Americans have been eating this stuff for over a decade without a single ill-effect.

As the extremists among them plan their activist campaigns using mobile phones, they see no irony in trying to convince us all that the aerials and masts which facilitate such coordinated action will fry our brains – and particularly our children’s brains – again despite the absence of any real evidence for such beliefs. They are the same kinds of people who once argued that steam trains would asphyxiate all their passengers if they travelled at more than 30 miles per hour, and that dangerous electricity could leak from uncovered light fittings. The trouble is that now they are believed.

It is in the context of this post-rational era that the notion of ‘lifestyle correctness’, founded largely on narcissistic health ideals, has come to shape the direction of people’s lives in ways that once characterised the power of formal religions. In place of faith in the creeds and tenets of the established church, we now follow slavishly the equally false promises of the health-promotion professions – those who would have us believe that if we lead the ‘good’ life we will have unending life and beauty.

This comparison between the pursuit of health and the search for God has been noted by a number of social commentators, including, for example, the Australian academic Deborah Lupton. In her book The Imperative of Health she argues:

‘In this secular age, focusing upon one’s diet and other lifestyle choices has become an alternative to prayer and righteous living in providing a means of making sense of life and death. “Healthiness” has replaced “Godliness” as a yardstick of accomplishment and proper living. Public health and health promotion, then, may be viewed as contributing to the moral regulation of society, focusing as they do upon ethical and moral practices of the self.’ (1)

While the new religion of health enables many people in our society to gain a sense of moral worthiness, it also provides a valuable means of censuring deviants – those new outcasts in a world where the concept of ‘zero tolerance’ has somehow become a ‘good thing’. (The currency of this term alone, in my view, is sufficient to illustrate the extent to which we have lost the moral plot.) People who are unwilling to succumb to what the late Petr Skrabanek (a renegade Czech medic) described as ‘Coercive Healthism’ – those among us with ‘bad habits’ – are the new outcasts in this increasingly fearful and intolerant world. It is, in the words of the east London GP Michael Fitzpatrick, the ‘Tyranny of Health’ which now surrounds us.

Michael Fitzpatrick works in Hackney and is a man who is in daily contact with the sick, and sometimes with the dying. Increasingly, he is also in daily contact with the ‘worried well’, people driven to fear the very world they live in by unfounded scares and inappropriate health promotion. And now he regularly encounters people who blame themselves for their own illnesses – those who have been persuaded that they are sick only because they have failed to lead the lifestyles that what he sees as an increasingly authoritarian government has prescribed for them.

In his book The Tyranny of Health: doctors and the regulation of lifestyle (2), Fitzpatrick’s simple message is: ‘Doctors should stop trying to moralise their patients and concentrate on treating them’, and he enlists the help of the microbiologist Renee Dubos to reinforce his point. Dubos commented in his book The Mirage of Health, written way back in 1960:

‘In the words of a wise physician, it is part of the doctor’s function to make it possible for his patients to go on doing the pleasant things that are bad for them – smoking too much, eating and drinking too much – without killing themselves any sooner than is necessary.’ (3)

And that, for Fitzpatrick, is the real job of the GP – not meeting ‘lifestyle education’ targets set by the state. Nor refusing to treat those who have allegedly brought ill health upon themselves. His job is that of the doctor, not the priest.

Fitzpatrick’s complaint, like that of Skrabanek who feared what he called the ‘Death of Humane Medicine’ (4), reminds us very much of George Bernard Shaw’s tirade against the medical profession made in 1909. In a speech to the Medical-Legal Society he berated the arrogance of the profession in invading the civil rights of individuals that would not be tolerated in any other area. In his conclusion he remarked:

‘The last thing I want to say to you is this: you must have the medical profession socialised because medical men are finding themselves more and more driven to claim powers over the liberty of the ordinary man which could not possibly be entrusted to any private body whatsoever.’

Nationalisation of the health service was not, however, seen as the all-important issue here. Shaw added that even in these circumstances ‘not for a moment do I suggest that the doctor should have any power to coerce the patient even for his own good.’

Shaw upset more than a few medics with his forthright views on the role of their profession. And few doctors then, as now, aligned themselves with his dictum that health is not something that should be pursued for its own sake. Shaw said: ‘Use your health, even to the point of wearing it out. That is what it is for. Spend all you have before you die.’

Shaw’s line here reflects very much an old Russian proverb which, if you visit our humble Social Issues Research Center office in Oxford where I am a director, you will find displayed as you enter. It translates simply as ‘If you don’t drink and you don’t smoke you will die healthy.’

A similar sentiment was also, and perhaps most famously, expressed by Samuel Langhorne Clemens, better known as Mark Twain. He commented:

‘There are people who strictly deprive themselves of each and every eatable, drinkable and smokeable which has in any way acquired a shady reputation. They pay this price for health. And health is all they get out of it. How strange it is. It is like paying out your whole fortune for a cow that has gone dry.’

It was Mark Twain, of course, who also urged us to be careful when reading health books. ‘You might’, he warned ‘die of a misprint’.

A hundred years on and we seem to have ignored all of these rather wise and liberal views, despite the clear evidence available to us of healthism’s negative consequences at both individual and societal levels. If we go back a little further into history, to the French Revolution say, then we start to see the origins in modern Europe of the very forces against which Shaw, Twain and many others have railed.

The transformations in public health philosophy in revolutionary France were founded on the ideology that instruction in diet and lifestyle were the keys to ensuring the eventual compliance of the French people. It was, therefore, perhaps no accident that the head of the first-ever government public health department in Europe, established in 1789 – the year of the revolution itself – was none other than one Dr Guillotin – more familiarly known as the inventor of an efficient decapitation device – the guillotine.

Commenting on this period of history Petr Skrabanek notes:

‘It is a paradox that the Age of Enlightenment, which destroyed the false certainties of religious dogmas and freed man from superstition, forged, at the same time, new chains for the enslavement of man, by regarding him as a machine, governed by materialistic and deterministic laws.’ (5)

Elsewhere in Europe in the eighteenth century, other types of coercion in health policy were beginning to develop. In Germany, for example, many medical journals included in their titles the term ‘medizinalpolizei‘ (medicine police), and later ‘gesundheits-polizei‘ (health police). The medical historian George Rosen has argued that the concept of medical police was part of a broader political force which sought to secure greater wealth for the merchant classes and the aristocracy by ensuring that workers were sufficiently fit for their semi-slave roles.

This trend, according to Paul Weindling at the Wellcome Unit for the History of Medicine led to more far-reaching consequences:

‘Medicine was transformed from a free profession, as it was proclaimed by the German Confederation in 1869, to the doctor carrying out duties of state officials in the interests not of the individual patient but of society and future generations.’ (6)

This convergence of state and medical interests was also reflected in Britain in the rise of the eugenics movement in the early 1900s, following publications by Francis Galton and others. The philosophy enshrined the belief that the quality of human stock could be improved, as in the case of other animals, by preventing the reproduction of those of lesser quality while encouraging propagation of the superior variety. The term ‘social hygiene’, which quickly followed the development of eugenic ideology, incorporated notions of genetic selection with concerns for sanitation, diet, personal lifestyle and childcare. While previously ill health had been seen as an unavoidable misfortune, it now became (at least in part) the result of bad habits.

The fact that such dangerous philosophies were seen as persuasive by health reformers was due in large part to the pressures to achieve ‘national efficiency’ prior to the First World War. From the point of view of Charity Commissioners and the medical profession, the number of ‘undeserving’ poor in society had become unacceptable and radical steps were needed to reduce such a burden in times of economic recession. The eugenic ideology, therefore, found favour across the political spectrum, with ‘left’, ‘right’ and ‘new liberals’ all in agreement that control of breeding and lifestyles was a legitimate role for the state. These patterns of convergence of the state and medical professions were the direct precursors, according to some historians and the New York professor of paediatrics, Hartmut Hanauske-Abel, for the ultimate expression of lifestyle and health prescription which lay at the heart of the philosophy of the Third Reich.

Similar patterns are also evident in the role of supra-governmental groups such as the World Health Organisation (WHO), which force quite narrow Western concepts of health into the agendas of developing countries – hence seat-belt wearing campaigns in Mozambique where the main form of transport is the water buffalo and cart. And Deborah Lupton again notes that under the prevailing discourse of ‘healthism’, the pursuit of health has become an end in itself rather than the means to an end. For WHO, health has become reified to the extent that it is defined by them as ‘a state of complete physical, mental and social wellbeing’ – a phrase which, given the points I have just raised, might be seen as having sinister overtones. As David Seedhouse, director of the National Centre for Health and Social Ethics in New Zealand, has noted:

‘…in pluralistic societies any claim to know objectively the constituents of a worthwhile life must at the very least be treated with caution.’ (7)

Seedhouse argues that the whole notion of ‘wellbeing’ should be dropped from WHO’s mandate. Not only is the concept too vague to be used as a measure of the effectiveness of health promotion, it smacks very strongly of the ‘we know what is best for you’ philosophy. Robert Downie and his colleagues, in one of the ‘bibles’ of health promotion used by WHO activists, show that they are clearly exponents of this paternalistic role. They note that ‘wellbeing’ can be viewed in one sense as a subjective judgement made by individuals about their own physical and mental states. Ordinary mortals, however, as opposed to health promoters, may have ‘illusions’ about their own wellbeing – they are not ‘feeling great’ at all. They say:

‘Subjective wellbeing…may be spurious and may arise from influences which are detrimental to an individual’s functioning or flourishing and/or to society.’ (8)

From this standpoint, the large lady in Polynesia, who is culturally valued because of her size and weight, and lives a contented and long life as a result, is deluded. Her Body Mass Index (BMI) of over 30 is contrary to WHO’s ‘objective’ measure of wellbeing – she is ‘obese’. She must, therefore, be ‘encouraged’ to become a more ‘normal’ size despite the fact that this will inevitably make her less culturally valued, and probably quite miserable. There is also no real evidence that she will live any longer either.

For Seedhouse and others, the concept of objective wellbeing, which is at the core of WHO’s philosophy, consists of nothing more than unfounded prejudice. It provides a ‘cover’ for health promoters whose real ‘intentions and preferences’, he suggests, ‘are becoming too obvious’ (9).

At the core of all healthism is a concern to eradicate risk in people’s lives. On the surface this appears to be a liberal, caring aim and is robustly defended by those in the health education and promotion fields. Risk, however, as the anthropologist Mary Douglas and others have pointed out, is now both a politicised and a moralised concept. Risk is now the secular equivalent of sin. In this sense exposing oneself to risk, when other options are available, is to act in a sinful manner.

But there is a further issue here, and that is to do with the (often arbitrary) definition of risk. Which particular aspects of lifestyle are to be defined as risky/sinful, and to which segments of society will persuasion be applied for the ‘good of society as a whole’? These are not abstract questions, for they raise yet another insidious component of healthism – its culturally divisive nature. Risk determination is undertaken by a relatively small, white, middle-class elite group in Western society – scientists and health professionals. These are people who, in the main, do not smoke, drink to excess or engage in promiscuous sexual activities. They have low-fat and low-sodium diets and tend to be over-represented in the gymnasium and aerobic exercise groups. (They might, to some people, also appear phenomenally dull.)

Engaging in risk – smoking, drinking, creating the possibility of sexually transmitted diseases, eating fat, sugar, salt and avoiding too much exercise – is characteristic of a different strata of society – the poor and marginalised, the working classes, ethnic minorities and ‘deviant’ groups. When the proponents of healthism are urging changes in lifestyle in order to achieve, in their terms, wellbeing, they are advocating changes for others much more often than they are for themselves. In this sense they are essentially moralists seeking to stigmatise specific members of society.

Charles Rosenberg, professor of the history of science at Harvard University, emphasises this point crisply:

‘Cultural values and social location have always provided the materials for self-serving constructions of epidemiological risk. The poor, the alien, the sinner have all served as convenient objects for such stigmatising speculations.’ (10)

The point about healthists is that they have what Mary Douglas calls a ‘sense of individual control over social forces’. Because of their relatively privileged positions they feel that they have a personal stake in the culture to which they belong, and therefore wish to adopt lifestyles to maximise such benefits. But, as the writer David Shaw points out in his book The Pleasure Police, in a somewhat less academic manner than Douglas and her colleagues:

‘Poor people – the starving, the jobless and the homeless, whether here or abroad, with children or without – are not the ones demanding bans on smoking, silicone breast implants or oily popcorn in the local movie theatre.…No, the alarmists – the Cassandras who see death where’er they look – tend to be people with higher than average education and socioeconomic status…who want to be absolutely sure they live long enough to enjoy it, except that they’re so busy worrying that they don’t have the time, energy and appetite to enjoy anything – and, in the process of trying turn their personal anxiety into public policy, they are also depriving the rest of us of much pleasure we should be able to take from life.’ (11)

The demonising of risk-takers has identifiable social and cultural functions which, in my view, run quite counter to positive forces which lie at the very roots of our evolution. We have attained the benefits of a safe and civilised world precisely because our ancestors were risk-takers. From an evolutionary psychology perspective the cognitive structures which shape our reasoning and our relationship with our environments – our natural competences – have been moulded not by our development in the mere 200 years of industrialised living but over the millions of years since the arrival of the early hominids.

Our modern skulls, suggest Leda Cosmides and many others in the field of evolutionary psychology, house stone-age minds – brains not yet adapted for the rapid transition from hunter-gatherer communities to the technological sophistication of the twenty-first century. Natural selection is a very slow process – there have not been enough generations for it to reorder our neural circuits to come to terms fully with our progress.

I am aware of the limitations of evolutionary perspectives, and I reject the notion that by identifying what has existed in our past we can determine what ought to be pursued in the present and in the future. Such shallow and untenable reasoning lies at the heart of many sexist, racist and elitist dogmas. It is, however, unlikely that we have been able simply to cast off what might loosely be described as ‘in our nature’ over the mere one percent of our evolution which has been characterised by organised agriculture and so-called ‘civilised’ living. And there is ample evidence, I would argue, that the desire to take risks, and experience the frisson of excitement which accompanies such activity, is still ‘wired in’ to the cortical structures which direct our lives.

We can seek to regulate risk-taking, in the way that we regulate equally natural desires for sex, dominance and pleasure. But I do not think that we can sustain a ‘safe’ society – one in which risk is the equivalent of sin – for very long.

When our society becomes too safe, we feel compelled to put risks back into our lives. Consider for a moment bungee jumping. Only in the context of recent shifts in contemporary living could such a mindless activity come to be considered attractive – something that people will pay to do – leaping off bridges and towers to be rescued from the inevitable fate of gravity by an elastic cord!

It is this sense of balance – the essential ingredient of our success as a species, and one which is so often expressed in what are now defined as ‘bad habits’ – that we are now in serious danger of losing. We need some bad habits, I suggest, in order to retain our subscription to the human race.

There is, of course, another sense in which our pursuit of health, as defined in terms of longevity, might prove to be unsustainable. It is already becoming apparent that having a large sector of society in ‘retirement’ – past the stage of productive input into the economy – has its drawbacks. The notion of the state providing financially for its elderly, for example, is fast disappearing. The scale of the pension swindles conducted by recent governments makes Robert Maxwell seem quite amateurish. We simply can’t pay people to live out their extended lives with any degree of dignity without a radical reshaping of state fiscal policies. And that, given the converged political world in which we now live, is unlikely to be achieved. Talk begins again of voluntary euthanasia, assisted suicide…but let’s not go down this depressing road again.

Maybe the way we resolve the dilemma is to redefine morality – for morality, after all, is always founded on expediency and adaptation. Could smokers become admired because of the selfless way in which they shorten their lives? Could the English breakfast – the heart attack on a plate – be recast as the food of saintly people who will, if we are to believe all the current health dogmas, quickly and economically drop down dead from a surfeit of cholesterol. Who knows?

Over a leisurely and congenial lunch in Oxford, which involved rather more than the recommended three units per day of alcohol, we persuaded my old chum Desmond Morris to write an article for publication on our website to do with food and eating from a zoologist’s perspective. We thought he would dash off a witty and interesting piece about lions and their taste for wildebeest, or something like that. Instead, what he sent me was a moving account of his mother’s death, which had occurred a short time before. The title was ‘A little bit of what you fancy’. In it he said:

‘It was a meal to make a food faddist swoon away in horror. My mother was piling her plate high with a greasy, fatty, fry-up of a mixed grill and tucking in with gusto. When I say “with gusto”, I mean she was eating with the urgent pleasure of a predator at a kill. Although she was born during the reign of Queen Victoria, she was more in tune with the robust food pleasures of the eighteenth century, when a feast was a feast, and nobody had heard about health foods, diet regimes, or table etiquette that demanded you chew each mouthful 32 times before swallowing.’ (12)

Desmond continued: ‘Watching her in action and trying my best to match her appetite, I glibly remarked that if she kept ignoring the words of wisdom of the health gurus and diet experts, she would die young. This may sound like a cruel thing for a son to have said to his mother, but the fact that she was in her 99th year at the time of the meal in question, helps to put my remark into perspective.’

After some eloquent attacks on the pontificators and what he terms the ‘diet fascists’, and after calling attention to man’s omnivorous nature, Desmond returns to the story of his mother:

‘When my mother was dying (just in time to avoid putting the Queen to the trouble of sending her a telegram, as she expressed it) I asked her if there was anything she wanted. “A gin and tonic”, she whispered. I had to feed it to her through a straw. “If you’ve got to go, you might as well go with a swing”, she said. And where food and drink is concerned, you might as well stay with a swing.’

That, for me, is more than sufficient reason to argue that bad habits are, indeed, of value – that they make us human.

Dr Peter Marsh is a director of the Social Issues Research Centre.

This is an edited version of a lecture given to the Institute for Cultural Research at the King’s Fund, London on 17 November 2001.

Read on:

Risk, science and society, by Professor Sir Colin Berry

Food science, by Tom Sanders

Eat, drink and be merry, by Sandy Starr

(1) Lupton, D (1995) The Imperative of Health: Public health and the regulated body, Sage Publications. Buy this book from Amazon (UK) or Amazon (USA)

(2) Fitzpatrick, M (2001) The Tyranny of Health: Doctors and the regulation of lifestyle, Routledge. Buy this book from Amazon (UK) or Amazon (USA)

(3) Dubos, R (1960) The Mirage of Health, Allen & Unwin. Buy this book from Amazon (UK) or Amazon (USA)

(4) Skrabanek, P (1994) The Death of Humane Medicine and the Rise of Coercive Healthism, Social Affairs Unit. Buy this book from Amazon (UK) or Amazon (USA)

(5) Skrabanek, P (1994) The Death of Humane Medicine and the Rise of Coercive Healthism, Social Affairs Unit. Buy this book from Amazon (UK) or Amazon (USA)

(6) Weindling, W (1989) Health, Race and Politics Between National Unification and Nazism 1870-1945, Cambridge University Press. Buy this book from Amazon (UK) or Amazon (USA)

(7) Seedhouse, D (1995) ‘Well-being: health promotion’s red herring’, Health Promotion International, 10(1):61-67

(8) Downie, RS, Fyfe, C and Tannahill, A (1990) Health Promotion. Models and Values, Oxford University Press. Buy this book from Amazon (UK) or Amazon (USA)

(9) Seedhouse, D (1995) ‘Well-being: health promotion’s red herring’, Health Promotion International, 10(1):61-67

(10) Rosenberg, C (1988) ‘The definition and control of a disease’, Social Research, 55(3):329

(11) Shaw, D (1996) The Pleasure Police, Doubleday. Buy this book from
Amazon (USA)

(12) Morris, D (2000) A little bit of what you fancy, SIRC website

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Topics Politics


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