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What is Healthism?
I found an excellent blog called The Health Culture
My new favorite blog.
Within it are two posts describing Healthism. See below in quotes for those two posts. I think much of our field practices healthism by having a tendency to judge and prescribe movements. As demonstrated in the previous post "Sounds of a Clinic"
the sounds of healthism are ripe in the modern clinic.
As with all -isms there is an implicit and or explicit judgment of another involved. In the case of healthism it is an elitist an moral point of view. When a person is in pain the last thing they need to feel is judgment.
Throughout history there’s been an understandable desire to find connections between our behavior and our health. Human beings have practiced health regimens involving diet, exercise and hygiene since antiquity. When medicine was based on the humoral theory of disease, for example, individuals were advised to purge the body in the spring and, in the summer, avoid foods or activities that caused heat. Bathing in ice water was recommended in the 19th century. Mark Twain quoted the advice: “the only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you’d druther not.”
In the second half of the 20th century many Americans adopted the idea that a ‘healthy lifestyle’ (diet, exercise, not smoking, etc.) was a good way to prevent disease and live longer. This particular attitude was a product of popular perceptions about health (a surge of interest in holistic/alternative practices, self-care movements such as Our Bodies, Ourselves) and prevailing social attitudes (such as desirable body images). Perhaps more so than in previous centuries, the growth of media consumption and the effectiveness of modern advertising allowed commercial interests (books, magazines, fitness merchandise, vitamins and supplements, weight loss pills, diet and energy foods, …) to exert considerable influence on health behavior.
Also at work was extensive media coverage of a presumed link between preventive lifestyles and risk factors for disease (conflicting opinions about salt and which type of fats to eat are good examples). Unlike the vague aphorisms of previous generations, this more modern source of health advice had the scientific backing of epidemiology, if not the proof that comes from randomly controlled trials.
One of the terms used to describe the enormous increase in health consciousness is ‘healthism.’ Judging from how I’ve seen the word used, it means different things in different contexts to different people. I’m going to describe a few of those meanings.
This post grew rather long, so I’ve divided it into two parts. In part one I discuss an anti-authority sense of healthism as well as healthism’s most common meaning: a sense of personal responsibility for health accompanied by an excessive preoccupation with fitness, appearance, and the fear of disease. Part two discusses the moralistic and anxiety-inducing qualities of the term, plus an odd use where healthism becomes another word for health itself.
Some people use the term ‘healthism’ to emphasize the imposition of health directives in an authoritarian manner. A prime example is the vigorous anti-smoking campaign waged by Nazi Germany in the 1930s. Supporters of smokers’ rights use ‘healthism’ in this anti-authoritarian sense when they object to limitations on the freedom to smoke whenever and wherever they please. When Frank Davis, a highly articulate smokers’ rights blogger in the UK, refers to ‘healthism,’ he is objecting to the infringement of his rights.
This anti-authority sense of healthism also gets used when referring to the advice that we should exercise more or give up our favorite foods simply because they contain excessive amounts of sugar, fat, and salt. I don’t know of any statistics, but I wouldn’t be surprised if this use of the term is especially popular in the US, a nation proud of its ‘don’t-tread-on-me’ tradition of rugged individualism.
Here’s an example of a patient resisting the health advice of an authority, described by a doctor writing in The New England Journal of Medicine:
After I had berated the patient for his obvious failure to comply with my recommendations to correct his “misbehavior,” he said, “You know, doctor, there is more to life than good health.” These words have helped me rein in my sometimes overzealous attempts to force patients into that glorious state of wellness and maintain a more realistic approach to the best possible state of health.
What distinguishes anti-authority healthism is the open acknowledgement that the injunction to be healthy is externally imposed. This differs from other versions of healthism where the pursuit of health is internally motivated and individuals have little or no awareness of the external origins of their motivation.
Healthism as excessive preoccupation with health
In 1980 Robert Crawford defined healthism as “the preoccupation with personal health as a primary – often the primary – focus for the definition and achievement of well-being; a goal which is to be attained primarily through the modification of life styles” (emphasis in original). He noted some of the signs of this emerging trend in the 1970s: A remarkable increase in the number of people exercising, jogging, and running. An aggressive anti-smoking campaign. The proliferation of popular health magazines. The increasing frequency of health-related subject matter in newspapers and magazines. Advertisements that appealed to the desire to be healthy, even when the product’s connection to health was entirely superficial.
In 1980, when preoccupation with health and fitness was new, it was remarkable. Today it is so prevalent that it’s almost invisible — we simply take it for granted. All around us are people who aspire to healthy lifestyles and hold themselves responsible for their health, and we don’t give them a second thought. (Healthism is all around us, yes, in the media, in advertisements, and on supermarket shelves. As far as individuals go, however, healthism is predominantly a white, middle-class phenomenon.)
Some changes in our behavior – exercise routines, for example – are no longer even associated with the pursuit of health. Other explanations have come to suffice: Self-discipline and control are virtues in themselves. Asceticism has an aesthetic appeal. Being fitter-than-thou provides moral superiority. We live, after all, in a consumer culture based on the promotion of self-image and the value of physical appearance. The change in our fitness behavior in the 1970s, however, was linked to the advent of healthism.
Why the time was ripe for healthism
How this transformation happened is a complex story that includes the history of medicine in the late 20th century. The status of the medical profession was in transition in the 1970s. Once the Western world had won the battle against infectious diseases, medicine was confronted with the prevalence of chronic disease. When immediate success on this front was not forthcoming, public confidence in medicine declined.
Highly vocal critics were ruthless in their eagerness to find fault with medicine: Ivan Illich (Medical Nemesis), Irving Zola (Disabling Professions), Eliot Freidson (Profession of Medicine), Thomas Szasz (The Myth of Mental Illness). There were many others who wrote in the popular press, influencing public opinion, whose names are less familiar today.
The decline in confidence in medicine was due in part to a general disillusionment that followed idealistic and unrealized hopes of the 1960s — the world did not turn out to be better place in the 1970s. All professions were subjected to harsh criticism, and medicine was no exception. There were also more specific forces at work, however, at least in the US. The implementation of Medicaid and Medicare, followed by managed care, had a major impact on the stature of the medical profession and on the dissatisfaction with health care among both doctors and patients. It seems reasonable to suggest that if there was a decline in both confidence in and satisfaction with medicine, the public may have been especially receptive to the idea that they should take responsibility for their own health by adopting healthy lifestyles.
The emerging economic and political climate at the time also contributed to the rise of healthism. After the exceptionally stable and prosperous post-WWII decades, the 1970s brought the oil crisis, the combination of double-digit inflation and high unemployment (stagflation), and a turn to the conservative, neoliberal right. In 1980, Ronald Reagan was about to begin his first presidential term. It was expedient to redefine health, access to health care, and unemployment as matters determined by the worthiness of an individual’s character. Self-help — the kind advocated by the promotion of healthy lifestyles — was preferable to government assistance.
Healthism’s legacy for social determinants of health
The political climate favored appealing to the individual even at the expense of society. Looking at the situation in 1980, Crawford believed that healthism’s emphasis on individual responsibility would turn out to be its most significant and unfortunate legacy. The message was: “I have only myself to blame if I fail to modify my behavior and subsequently suffer the health consequences.” Crawford foresaw that the elevation of the individual would work against the search for collective solutions to environmental and occupational threats to health.
Our understanding of the determinants of health has advanced considerably since 1970s concerns about the dangers of air pollution and the inhalation of asbestos on the job. There is now extensive evidence, for example, that health disparities are due to social class itself and not just lack of income or access to health care. The fundamental problem, however, is the one Crawford identified: By focusing on the individual and not the society in which the individual lives, medicine, the health care industry, and governments have failed to address the ultimate causes of disease.
Healthism contributed to this failure. Ironically, the explosive preoccupation with health in the late 20th century has been a formidable hindrance to achieving the improvements in health we claim to seek by practicing healthy lifestyles.
In part one of this post I explained the most common meaning of healthism (an excessive preoccupation with healthy lifestyles and feeling personally responsible for our health) and described an authoritarian sense of the term. Here I discuss healthism as an appeal to moral sentiments and as a source of anxiety. I also note an unusual definition of the term as the desire to be healthy, which leads me to end with a personal disclaimer.
The directive to be personally responsible for our health – whether it comes from a government health policy, the medical profession, or an advertisement – is often fraught with unacknowledged moral overtones. People who practice healthy lifestyles (daily exercise, a Mediterranean diet) and dutifully follow prevention guidelines (annual cancer screenings, pharmaceuticals to maintain surrogate endpoints for risk reduction) are overtly or implicitly encouraged to feel morally superior to those who do not. This includes the right to feel superior to those who ‘choose’ to be unhealthy – after all, isn’t smoking a morally indefensible choice? The implication is that those who fail to take responsibility for their health are undeserving of our sympathy or assistance (especially financial).
This quality of healthism – like the anti-authority healthism discussed in part one – is possibly more common in the US than elsewhere. It’s unfortunate but true that in the US there’s a tendency to blame the poor and disadvantaged for not being able to pull themselves up by their bootstraps. There is a decided unwillingness to acknowledge that differences in wealth and social class during childhood have lifelong effects on behavior and health.
As sociologist Marc Renaud writes:
One’s capacity to modify potentially pathogenic behaviours and to “stick with it” is directly related to one’s wealth, power, and education — in short to the degree of control one has over one’s future. The higher up in the social hierarchy, the more control one feels capable of exerting over life, the easier it is to change unhealthy habits. In other words, one’s “will to change” is largely predetermined by one’s social environment. To be told, by an education program or otherwise, that one’s life-style should change is neither helpful nor effective.
If a boy grows up surrounded by drug abuse, gang violence, and an abbreviated lifespan for the adult men in his life, it’s unlikely he’ll worry about the possibility of lung cancer 20 years from now.
In an attempt to slow escalating health care costs in the 1970s and ’80s, moral healthism was a convenient way for politicians — at least symbolically — to shift the burden of responsibility for health onto individual citizens. It remains a popular position among politicians who would like to blame high health care costs on those who allegedly eat too much. In addition to serving political interests, moral healthism is used by vendors of health-related goods and services to motivate consumers to make purchases (gym memberships, organic food, diagnostic screening).
When healthism refers to a superior moral attitude, it’s meant to be pejorative and disparaging. People who take pride in the nutritional correctness of what they eat, the size of their muscles, or the absence of any flesh that’s not firm may be examples of healthism in action, but those individuals would not use that term to describe their behavior. At most they might admit to being health and/or body conscious.
Another quality of healthism is anxious preoccupation with health. If we believe we’re personally responsible for our health, it follows that we should worry about whether our behavior is sufficiently health promoting. This attitude is a favorite of pharmaceutical companies (“ask your doctor”) and the food industry (“heart healthy”). It’s also a natural by-product of medicine’s increasing emphasis, since the 1950s, on risk factors for disease.
Moral and anxiety healthism often overlap. When healthism is used by pharma, the food industry, the fitness industry, and the purveyors of medical products and services, there’s usually an element of both anxiety (you should be worried about your health) and morality (you can feel good about yourself if you do (or bad if you don’t)).
Anxiety about health is fueled by all forms of media, both through advertising and by the barrage of information on the latest (often contradictory) health findings. When media companies benefit financially from the public’s interest in and vulnerability to health information, they’re practicing anxiety healthism.
Historically, there may be a connection between the origins of healthism in the 1970s and anxiety. Robert Crawford suggests that the economic insecurities and uncertainties of the 1970s may have prompted efforts to control our health as a way to reduce anxiety. When we can’t control the world around us, we can attempt to keep anxiety at bay by increasing control over ourselves.
It’s only natural that we want to exert some control over our health, our susceptibility to illness, and the length of our lives, no matter which anxious decade we live in. Increased anxiety about health, however, makes us vulnerable to the promotion of lifestyle changes (and their associated consumer products) that will ‘guarantee’ good health. The obsessive pursuit of health, accompanied by anxiety, is in fact unhealthy.
Healthy healthism: Profiting from moral and anxiety healthism
Although it’s exceptional, some people use the term healthism to refer to the desire to be healthy (“Healthism – A Way to Become Healthy“). I’ve come across only two examples of this usage, one in India and the other in Canada. It’s a very ironic sense of the term, since it uses the moral, guilt-tripped compunction to be healthy to promote and profit from anxious, health-seeking behavior.
The president of the Healthism.com site in Canada (in an email exchange) agreed with me that healthism is about personal responsibility for health, but not that the term is pejorative. He believes those who are “marginalized” in society should be held to the same standards as the affluent when it comes to personal responsibility for health. To believe otherwise is “typical academic elitism.”
Healthism.com promotes diagnostic testing and promises to sell “doctor-reviewed products for your health and vitality.” While the site may choose to define healthism as the desire to be healthy, it’s an excellent example of practicing moral and anxiety healthism to profit from our vulnerability to health concerns.
What can I say? In a post-1984 world, people redefine words to mean their opposite all the time.
Obviously, in just two posts, I haven’t exhaustively captured all possible meanings and nuances of the term healthism. People disagree, for example, about what it means to be personally responsible for one’s health. When Irving Zola first used the word healthism in 1977, his meaning was virtually identical to an early use of the term medicalization.
I will leave for later a response to the accusation that, because I find moral and anxiety healthism objectionable (I hope that’s obvious), this must mean I believe everyone should smoke, be overweight, and never be tested for cancer. (When discussing healthy lifestyles, I really do get this reaction from otherwise highly intelligent people.) That’s not what I think, but it would take more than a few posts to explain what I find so objectionable about personal responsibility for healthy lifestyles. It’s a sign of the effectiveness of the personal responsibility message that many people fail to examine the interests it serves. I myself was once in that category, which is one reason I feel so strongly about the subject today.
A preoccupation with healthy lifestyles to the point of healthism is a coping mechanism in an unhealthy world, just as smoking and substance abuse are mechanisms for coping with the stressors of modern life. It is not the practitioners of healthy lifestyles I find objectionable, but those who exacerbate and profit from our anxiety about health.
I write about the history of healthism because I’m interested in medical, political, economic, cultural, social, and historical factors that influence the way we think about health and health policy today. Changes in health policy cannot happen unless the public understands what ultimately determines health and illness. Healthism — personal responsibility for health by practicing healthy lifestyles — has had an enormous influence on the public’s perception of health. By turning our attention away from the larger social environment in which we live, healthism has reinforced biomedicine’s assumption that our understanding of health must be limited to the narrow confines of the laboratory and the doctor’s office.
Our financially and professionally entrenched system of medical care has a vested interest in maintaining an understanding of health that preserves the status quo. Part of the power of our biomedical culture, however, is that its contingency – the very real possibility that it could be different — is ordinarily invisible to us. What would it take to imagine a widely shared understanding of health that valued not only the quality and availability of health care, but daily living conditions that are conducive to everyone’s health? This is the question I hope an examination of healthism will provoke.
Eric Kruger DPT, Twitter @Kintegrate
Body is imbued with mind, and mind is embodied.
I know that I effect, but I know not how I affect.
"Your pain is the breaking of the shell that encloses your understanding.”–Kahlil Gibran (1883–1931). The Prophet.