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Julian Sheather: Public health and social power

29 May, 14 | by BMJ

julian_sheatherIt’s hard not to brood from time to time on some of the intractable public health problems that entangle us. Take obesity. Swimming with my boys over the weekend, I was again struck by how much the food that should sustain us is killing us. It’s hard as well not to wonder where change might come from. We know that obesity arises at the juncture between appetite and environment, between private choices and systems that constrain and encourage, between our evolved appetites, the supermarket shelves, and our all too wavering wills. We champion individual and commercial freedoms—freedoms to buy, freedoms to sell—but the private exercise of our liberties is everywhere undoing us.

We know that change will somehow have to address both the regulation of our desires, and also the great social playgrounds in which our desires roam. Partly it is a private issue—what I eat is my business—and partly it is a public one, as cumulative private choices can become big social problems. Although for thousands of years we approached the problem of appetites via the virtues, we now quail at any public suggestion of moralism, preferring the quaint and neutral fiction that we are all rational economic actors and that we can be entirely taxed into good health.

Current responses to obesity seem to take one of two almost opposing forms. On the one hand, from the commanding heights of our health institutions flow a steady stream of ever more chilling forecasts and of ever more elaborate instructions on how to prosper: was I the only person to sigh a little when five a day became seven? On the other hand, from the ground up, from the champions of personal liberty, come suggestions on how to massage our private choices. Against the paternalism of institutions come the gentle tweaks and nudges of market based solutions, a reshuffling of the grab bags next to the till. Somehow, together, they remind me of the wonderful Marilynne Robinson. “I think we have not solved the problem of living well, and that we are not on the way to solving it, and that our tendency to insist on noisier and more extreme statements of the new wisdom that has already failed us gives us really very little ground for optimism.”

Thinking about these things, I came across a fine talk by Matthew Taylor, over at the Royal Society for the encouragement of Arts, Manufactures, and Commerce, on the sources of social power. At the risk of flattening and simplifying his nuanced thought, he identifies three basic forms of social power: the hierarchical, which in this context roughly translates as government and the commanding health institutions; the individualistic—our private “lifestyle” choices; and the solidaristic—our social habit of doing things together in interest groups: churches, sports clubs, trade unions. These boil down, as he puts it, to the following: I’ll do what I’m told (hierarchy), I’ll do what everybody else does (solidarity), and I’ll do what I want (individualism). Genuine social change—and this could not be more relevant to public health—involves all three forms of social power working together in, at times, tense and conflicted alliance (there is an inherent instability here and equilibriums seldom last long).

But these forms of social power have become unbalanced. Our hierarchies are crumbling, partly through failure, partly through loss of public trust, and partly because we have all just become less deferential; and we are losing, through complex factors, our habit of doing things together. As a result, individualism is overburdened. In our culture we are simply asking the poor, solitary, isolated individual to do things which are beyond his or her power.

Real social change can only come when all three forms of social power work together, and this requires wide ranging renewal. Our hierarchies need to regain their authority, and in doing so they must respond to public demands for honesty, accountability, and transparency. Our habits of doing things together—which are an enduring aspect of our species being—need to be reinforced, and we need to be far more realistic about the limits of our individualism.

Olivia Laing, writing in a recent Granta about the artist David Wojnarowicz, recalls an earlier public health crisis:

Between 1981 and 1996 when combination therapy became available, over 80 000 people died of Aids in New York City, most of them gay men, in conditions of the most horrifying ignorance and fear. Patients were left to die on gurneys in hospital corridors. Nurses refused to treat them, funeral parlours to bury their bodies. Politicians blocked funding, while public figures called for those with Aids to be tattooed with their infectious status and quarantined on islands.

She also recalls how the gay community refused to be silent. How it came together. How, in the East Village, David Wojnarowicz, along with the artists Keith Haring, Zoe Leonard, and Gregg Bordowitz, joined the group ACT UP, which, mining the same vein perhaps, stands for Aids Coalition to Unleash Power. ACT UP “protested the Catholic Church’s stand against safe sex education in New York public schools and used sit-ins to force pharmaceutical companies to make medication affordable and to open clinical trials to drug addicts and women.”

Real change in public health will involve the exercise of all three forms of social power. We need our politicians and our health experts to make the best of current expertise available to us, but we also need them to be honest about the limits of their knowledge. We need to change our consuming environments—tax and nudge can help—but we also need to be clear that individual choices matter, and that means taking responsibility. But critically it also involves renewing our ability to work together. Where hierarchical authority is in crisis, where individualism is overburdened, we need to find our way back to trusting each other just enough to work together to tackle the threats to our wellbeing.

Julian Sheather is ethics manager, BMA. The views he expresses in his blog posts are entirely his own.

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