Professor Sir Michael Marmot
Sunday 15 August 2010 09.04 AEST
Professor Steve Field says it is up to individuals to take responsibility for their own health. I agree. Except that insight does not provide much of a guide to knowing what to do. The evidence suggests that simply telling people to behave more responsibly is no more likely to be effective than telling someone who is depressed to pull his socks up.
Nor does a focus on individual responsibility take us far in understanding the health problems we face as a nation. A striking feature of smoking and obesity is their close link with people's socioeconomic position: the lower their status the more likely are people to be obese and to smoke. Suppose you were tempted to think that the poor are simply irresponsible. How would that explain why among people who work hard in stable jobs, those with less education are more likely to smoke?
In my review of health inequalities, Fair Society, Healthy Lives, we drew attention not only to the causes of ill-health but to the causes of the causes. Smoking, obesity and heavy drinking are causes of ill-health, but what are the causes of these behaviours?
The behavioural choices we make as individuals are rooted in our social and economic circumstances. People born into more advantageous situations find it easier to adopt healthy lifestyles and give up unhealthy behaviour.
Such differences are part of the explanation for the striking social differences in health. For example, in England, there is a finely graded relation between the affluence of a neighbourhood and healthy life expectancy. Systematic differences in health cannot be attributed to genetic make-up, lack of personal responsibility or difficulties in access to medical care. They are linked to the conditions in which we are born, grow, live, work and age.
Rather than simple exhortations to behave better, we need to address these more fundamental causes of ill-health. That does not mean there is nothing to be done in the short term. In my review, we drew on the evidence of the success of interventions at population level to prevent people from starting smoking and helping them to quit: smoking bans, reducing smuggling, restricting advertising and placement, workplace interventions, group therapy, counselling, self-help materials, nicotine replacement therapy and social support, and abolishing prescription charges for nicotine-replacement therapy.
Professor Field emphasises, rightly, the role of GPs. There are impressive examples of GPs putting their actions in the context of the lives people are able to lead. The Bromley by Bow Centre promotes healthy lifestyles to individuals living in deprived areas of east London by offering a range of innovative services on one site, including a GP surgery, adult education, children's centre, art classes and advice on issues such as housing, benefits and employment. It takes a holistic approach to improving health by working in a social partnership to increase employment, skills, social capital and integration, and therefore helping people to have control over their lives.
We must dispose of a false opposition: the nanny state against individual freedom. It is up to individuals to make choices that will influence their health. But individuals will only be able to change behaviour through choice if they have control over their lives and that requires creating the conditions to allow them to do so.
Put simply, childhood deprivation, the stress of poverty, overcrowding, living in a run-down area, feeling powerless at work and being unemployed do not give people the control over their lives that fosters good health and enables them to succeed in making difficult changes in behaviour.
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