Feature

Health off the shelf?

The idea of ‘health promotion’ is becoming central to the way we live. But is it necessarily a benign force? Robin Bunton examines the arguments

Concern for healthy lifestyles has increased dramatically in the last twenty years and with it there has been a parallel growth in health promotion. Individuals, governments, commercial interests and the media have all played their part in building a new agenda for healthcare. Health promotion messages are now directed at us in supermarkets, on the television and radio and in women’s and, more recently, men’s magazines. Health is a live issue politically and culturally. In the 1990s health promotion is no longer a rather marginalised part of the national ‘illness’ service but a thriving element of mainstream healthcare. In the UK we have moved a long way from the tentative statements in Prevention and Health: Everybody’s Business published by the Department of Health and Social Security in 1976. In the last five years targets have been set by The Health of the Nation to which all health authorities are working and health promotion work has been initiated in most general practices under government direction.

These rapid developments have not occurred without criticism. Many people have voiced a concern that newer, ‘gimmicky’ health promotion activities merely serve as a smoke screen masking other fundamental changes - particularly cuts in service provision and ‘creeping privatisation’. In a sea of changes it is sometimes difficult to determine whether the new approaches represent improvements and what, if any, are their long-term social effects.

On the whole sociologists have welcomed the introduction of health promoting measures, seeing in them increased support for a more social model of health and a recognition of the role social structure has in determining health and illness. But recently more critical scrutiny has been directed towards health promotion and the new public health. The Sociology of Health Promotion reports on a conference held at Teesside University drawing together more critical perspectives on health promotion. From these standpoints, health promotion is far from a universal clarion cry of progressive health radicals. When placed in broader social contexts it becomes integral to some more familiar and less attractive socio-political changes.

Social inequalities

Health promotion has developed globally. Current UK policy documents reflect WHO statements and those of numerous other countries which have appeared since the early 1980s. What is interesting about UK policy documents such as The Health of the Nation is what they have left out. The firm commitments to eradicating health inequalities made in many other countries are absent, as too are strong central government initiatives and means of monitoring policy processes towards the stated health targets.

A cursory examination of current national health promotion policy and that of local and general practice suggests that previous sociological critiques of health promotion still apply. The failure to take account of structural disadvantage and its effects on people’s health and a continued focus on individual lifestyle change is a serious drawback. Unless the other structural elements of health inequality are addressed, health promotion, by appealing to higher income groups more successfully, will accentuate not reduce inequalities. Moreover, it is apparent that ideas about healthy living are primarily put by mainly white, middle-class professionals often working within sexist, racist and homophobic value systems. These more familiar accusations are still applicable to contemporary Britain although there are now other critiques building upon newer social analyses.

Social surveillance

Health promotion, like many aspects of contemporary healthcare, is concerned for those ‘at risk’. Health promotion employs a number of often quite intrusive techniques to build a risk profile on the community and its characteristics such as diet, drug intake, sexual activity, exercise and so on. While constructing potentially useful health profiles, these techniques also introduce new ways of mobilising populations and subtly handing over responsibility for health to individuals and communities. Health promoters appear to be listening more attentively to non-professional views on health. The effect of this approach is to transfer responsibility for health and to introduce new forms of risk management and insidious control. New types of control over our lives may be introduced in the name of health, from random drug testing at work and school to compulsory health counselling. As with a recently reported heart disease case, it will be possible to link ‘deservedness’ of surgery to lifestyle risk factors. These newer developments have implications for civil liberties.

At the same time newer approaches to health reflect broader concerns of the late twentieth century where constant changes in social life have made ‘risk management’ a personal and societal concern. We live lives in which we must perpetually risk profile our job opportunities, our personal relationships and the environment we live in for wealth and crime potential. Health risks are yet another aspect of this relentless reflexiveness.

Health and consumer culture

Another important development is the increased importance of consumer culture and shopping with an associated preoccupation with the body and lifestyle. ‘Healthism’ has become a central plank of contemporary consumer culture as images of youthfulness, vitality, energy and so on have become key concerns. Contemporary health promotion dovetails easily with changes in consumption and acts to enhance private marketing growth areas.

In the 1960s a list of ‘health-related’ commodities was quite limited, including items such as aspirins, TCP, Dettol and Elastoplasts. By contrast, today we can add: food and drink; a myriad of health promoting pills; private health insurance; alternative medicine; exercise machines and videos; sport and health club memberships; walking boots; running shoes; plastic surgery; shampoo (for ‘healthy-looking hair’); sun oils; psychotherapy; aromatherapy; shell suits; and so on. The list is seemingly endless. Some commonplace commodities have taken on health-related value. Household cleaning products, for example, are sold on their ‘green’ credentials. Other, newer health products have been given a much wider social and cultural meaning. Running shoes, shell suits and body building have become signifiers of social success and worth. The widely reported case of a couple naming their newly-born son Nike is indicative of this.

Health promotion campaigns are increasingly indistinguishable from other forms of health product advertising. Health promoters draw upon similar social marketing techniques and often work collaboratively with product promoters and advertising teams. Health promotion is helping to reach the parts previous marketing has not touched. While we might convince ourselves that we are buying into new lifestyles and new ways of living, the array of options available has been carefully constructed, keeping the myth of self-actualisation very much alive and kicking. To formulate views on health promotion, we need to clarify our attitudes to new consumption patterns and the issues these present.

Social critique

A social critique of health promotion as it is currently pronounced and practised is emerging. Health promotion has been something of a ‘hurrah term’ - easy to applaud but hard to do anything about. This more recent critique is timely. If health promotion is becoming a central feature of contemporary health systems then we need to consider the implications, not simply for our health but for our lives as a whole. Is the current rendering of health promotion how we wish to live? Does health promotion create too many unwarranted moral dilemmas? Are we in a position to deal with these? Are healthcare purchasers in a position to deal with these issues?

Current social critique is beginning to place these issues within broader debates about social surveillance, risk management, professional knowledge and power, consumer culture and consumer power, personal identity, cultural change and health inequalities. To understand recent developments in health promotion we need to understand better recent developments in society at large.

The Sociology of Health Promotion: Critical Analyses of Consumption, Lifestyle & Risk is edited by Robin Bunton, Sarah Nettleton and Roger Burrows and published by Routledge in June 1995.