Tag / public health
Public Health has a Tobacco Problem
The widely circulating media reports that compare bacon to tobacco in terms of its capacity to cause cancer reveals the “tobacco problem” with public health communication.
By “tobacco problem” I don’t mean that researchers or communicators are on the take from “Big Tobacco” or that they have got the facts wrong about its association with cancer. The tobacco problem is that the success of tobacco control has produced a conceptual and political myopia. Or what I call a “tobacco control style of thought”.
Ian Hacking describes a “style of thought” as a particular way of seeing the world or problem that allows some ideas to be thinkable and actionable, while rendering other ideas as unthinkable. The success in linking smoking with cancer and the implementation of controls to regulate its use have contributed to a tobacco control style of thought.
The effect is that all public health issues are shoe-horned to fit the tobacco control model.
Eating bacon and red meat, drinking soda or frequenting fast-food restaurants, or sitting in a chair for too long are all equated with smoking. Why? Because saying bacon is like tobacco means that the problem and corresponding solution is well understood by the public and policy-makers.
Except it isn’t. All of these activities are extremely different from smoking. Eating bacon is not the same as smoking cigarettes. Everyone outside the tobacco control style of thought can see this.
The Australian Agriculture Minister Barnaby Joyce said it is a “farce to compare sausages with cigarettes“. Does Barnaby have financial and political interests in saying that? Yes. Is he wrong in saying that? No.
Sure, saying “bacon causes cancer” generates headlines, but it also distracts from focusing on the actual research on the health effects of processed meats. Public health communicators and researchers need to break out of the tobacco control style of thought that makes bacon or soda look like tobacco.
Public health is currently in a battle with libertarians who cry “Nanny” every time they are told that an activity or behaviour should be regulated. However, in equating activities like eating processed meat or sitting at a desk with smoking, public health communicators give the appearance of legitimacy to the “Nanny State” cry. This does real damage to the credibility of public health research and erodes public understanding of risk factors and epidemiology.
Like the boy who cried wolf, if public health communicators continue to compare everything to smoking, soon people will stop listening.
Lifestyle choice: a brief note
I’m currently completing a book manuscript called ‘The Biopolitics of Lifestyle’. So when Tony Abbott made his comments that Aboriginal’s living in remote communities are making a ‘lifestyle choice’, I thought “great, I may need to write another chapter”.
This is not simply a poor choice of words, but reflects a governmental rationality that seeks to place responsibility on to individuals. Education, health, welfare, employment all become ‘lifestyle choices’ for which the individual is responsible.
The affluent, gainfully employed, highly educated sections of society make good ‘lifestyle choices’, while the poor, sick, Indigenous and asylum seekers are characterised as making bad ‘lifestyle choices’.
Abbott is not the first to use this phrase to justify . In 2002, Philip Ruddock described asylum-seekers as making ‘lifestyle choices’.
“In the main, people who have sought to come to Australia and make asylum claims do not come from a situation of persecution; they come from a situation of safety and security,” he said.
“They may not be able to go back to their country of origin but they are making a lifestyle choice.” The Australian, ‘Ruddock blames “lifestyle” refugees’ by Alison Crosweller and Megan Saunders
This governmental rationality shifts responsibility away from governments and communities, and on to individuals. It also serves to trivialize some claims (living in a remote community or seeking asylum) by comparing them to frivolous consumer lifestyle choices (Pepsi or Coke, holden or ford, apple or pc).
Of course, when we talk about the Australian Lifestyle of ANZACs, footy, beach, sun, boats, and weekends, things get very serious. Governments use this notion of lifestyle to build monuments, go to war, and demonize minorities. But that is another matter all together.
In the current context the rationality of ‘lifestyle choice’ shifts responsibility onto individuals in remote communities and justifies the Western Australian government’s decision to cut services and remove people.
Depoliticising Indigenous Health via Consensus and Statistics
‘Politics’ has become a dirty word in Australia. To ‘politicise’ an issue is regarded as obfuscation. Good governments ‘govern’ and make ‘policies’. And good oppositions should work with governments to produce policies not debate endlessly, or so we’re told – usually by sitting governments.
While a lot of the ‘politics’ has devolved into oppositional tactics, political debate is essential for democracy.
At a minimum political debate should reveal the reasons and justifications for a particular policy. However, false consensus and the use of statistics are increasingly used to depoliticise debate of important issues. A recent example is Indigenous health.
Indigenous health is an area where “every opposition wants the government to succeed”. However, perhaps it is this consensus that has resulted in continual failure.
The 7th Closing the Gap report was presented in Parliament earlier this month. Prime Minister Tony Abbott gave a sobering speech, noting that most targets were not on track “despite the concerted effort of successive governments since the first report”.
Opposition Leader Bill Shorten, however, called on the Government to reverse the budget cuts to social services that disproportionately affect Indigenous populations and compound existing inequalities. Coalition MPs were unhappy with this suggestion. Some walked out and others said Shorten was playing political games on an important occasion.
The focus on consensus – that everyone wants to Close the Gap – has reduced Indigenous health and education to a national human interest story. It is bracketed from the realm of politics and serves either to inspire or a cathartic release. Sociologist Pierre Bourdieu writes that “human interest stories create a political vacuum. They depoliticize and reduce what goes on in the world to the level of anecdote and scandal”.
In breaking with the ritual bipartisanship, where Opposition and Government solemnly agree that “more should be done but it is all so very difficult”, Bill Shorten re-politicised Indigenous health, if only briefly.
While liberal political philosophy values consensus established via publicly justifiable reasons, when consensus is assumed, publicly justifiable reasons become redundant. The presumption of consensus between the two major parties on indigenous health (and anti-terror legislation and asylum seeker policy) lowers the expectation of rigorous political arguments for or against certain positions.
Shorten broke with the consensus game and exposed the gap between Abbott’s rhetoric of “concerted efforts” and the first budget he delivered. Budgets are not simply economic documents, but reflect political and moral decisions about the lives that are valued.
Politics of Life Expectancy
Not unrelated, last month Treasure Joe Hockey attracted ridicule with his comment in a 3AW interview ‘that somewhere in the world today, it’s highly probable, that a child is being born that is going to live to a 150’.
Hockey’s comment received some support from Professor Peter Smith who points to advances in medicine and public health as reasons to expect a continued increase in human life expectancy.
Professor John Quiggin however suggested that these claims are highly dubious and ignore the fact that the extension of life expectancy in the 20th Century ‘came from a reduction in death rates for the young.’
Will Cairns also pointed to the success of reducing death rates. Writing in the Medical Journal of Australia that
our numbers plummet as we approach 100 years of age because all of these interventions [public health, disease treatment, nutrition] make no difference to the reality that we eventually wear out and die. Apart from the odd unverified outlier, only one person has ever been confirmed as living for more than 120 years.
Hiding Politics in the Statistics
Like the assumption of a consensus, Hockey’s use of life expectancy statistics to justify changes to the health system hides the political nature of these decisions.
Altering the financing of the health system through strategies such as co-payment schemes may appear reasonable. We are told Australia’s population is ageing and more people need to use the health system. However, what these statistics hide is the disparities of life expectancy in Australia.
While a child may be born today to live to
150 120, the latest ‘Closing the Gap‘ report reveals that Indigenous Australians born today can expect to live more than a decade less than non-Indigenous Australians.
The reality of significant gaps in life expectancy should be the cause for alarm and inspire the creation of a more equitable health system. Yet often population statistics hide the details. As Professor Mick Dobson notes, ‘Statistics of shortened life expectancy are our mothers and fathers, uncles and aunties who live diminished lives. We die silently under these statistics.’
Statistics: measuring and managing people
Vital statistics have been used to govern populations since the 17th century. But it’s important not slide over the word “statistics” too quickly as its literal meaning is hidden through repeated use.
Statistics is not simply about numbers but “state craft“. By knowing birth and death rates, and the incidence of disease it is possible to establish probabilities of epidemics, movement of people, and to order the State in a rational manner.
Vital statistics also enable the segmentation and division of populations. We see this all the time in professional sports. The explosion of statistics about batting averages, field goal percentage, or a players historical probability of kicking a goal from a certain angle against a certain team all help coaching staff to know who is performing and who is not.
Divisions in the details
Despite appearances, the use of statistics as political tool for governing a population is not neutral. Historian and philosopher Michel Foucault notes the way vital statistics introduce a power over life or biopolitics. The increased knowledge about nutrition, physiology and sexuality in the 19th century lead to the creation of norms from statistical averages that allowed political strategies to regulate human life.
Statistical analyses are used in public health to show the distribution of disease and enable interventions in populations. But as Foucault notes, these techniques also allow the identification of lives that are healthy and should be fostered and which lives are not performing and can be neglected.
A danger with the celebration of a statistically increasing life expectancy, is that it masks the very real health inequalities faced by many Australians. This is seen in a number of areas:
- allow for certain health issues to be prioritised (e.g. ageing population), while others marginalised (e.g. health inequalities)
- enable the allocation of funding towards some research (e.g. Medical Research Future Fund), while moving it away from other areas (e.g. preventive health)
- suggest a particular financing models for the health system (e.g. co-payment), yet discount others (e.g. progressive taxation).
These are not simply economic decisions, but political and ethical decisions about which lives count. For too long the supposed neutrality of statistics and the assumption of consensus have allowed the political reality of Indigenous health inequalities to be hidden. To close the gap we need to recognise the historical and political processes that have made it and maintain it.
Bioethics, obesity and the harm principle
Fat people should pay more to fly, because they weigh more and hence use more fuel.Fat people can’t make good food choices so they should be coerced and stigmatized into making the right choice.
The Harm of Bioethics: A Critique of Singer and Callahan on Obesity
Debate concerning the social impact of obesity has been ongoing since at least the 1980s. Bioethicists, however, have been relatively silent. If obesity is addressed it tends to be in the context of resource allocation or clinical procedures such as bariatric surgery. However, prominent bioethicists Peter Singer and Dan Callahan have recently entered the obesity debate to argue that obesity is not simply a clinical or personal issue but an ethical issue with social and political consequences.
This article critically examines two problematic aspects of Singer and Callahan’s respective approaches. First, there is an uncritical assumption that individuals are autonomous agents responsible for health-related effects associated with food choices. In their view, individuals are obese because they choose certain foods or refrain from physical activity. However, this view alone does not justify intervention. Both Singer and Callahan recognize that individuals are free to make foolish choices so long as they do not harm others. It is at this point that the second problematic aspect arises. To interfere legitimately in the liberty of individuals, they invoke the harm principle. I contend, however, that in making this move both Singer and Callahan rely on superficial readings of public health research to amplify the harm caused by obese individuals and ignore pertinent epidemiological research on the social determinants of obesity. I argue that the mobilization of the harm principle and corresponding focus on individual behaviours without careful consideration of the empirical research is itself a form of harm that needs to be taken seriously.
Keywords: obesity; Peter Singer; Dan Callahan; harm principle; public health
Mayes, C. (2015), The Harm of Bioethics: A Critique of Singer and Callahan on Obesity. Bioethics, 29: 217–221. doi: 10.1111/bioe.12089