What life is this? Some concluding thoughts
What life is this? Some concluding thoughts
Abstract and Keywords
This chapter provides some concluding thoughts about the book. Both the UK and US are undergoing major governance upheavals. In the UK, the arrival of the coalition government in May 2010 instigated great debate about the future of public services and, therefore, the kinds of behavioural expectations, rights and responsibilities being placed on citizens. In the US, Barack Obama has toiled to push health up the agenda, passing the landmark health care reform bill through the Senate in early 2010 and has since faced constant threats from the Right to repeal these advances. This chapter also revisits the three core contentions of the book before dwelling in greater detail on the key findings and significance of this work. It also takes into account eating, exercising and drinking, as well as discrete lifestyle risks.
As I write this conclusion, the UK and US are undergoing major governance upheavals. In the UK, the arrival of the coalition government in May 2010 instigated great debate about the future of public services and, therefore, the kinds of behavioural expectations, rights and responsibilities being placed on citizens. This renewed debate is notable principally because it demonstrates the temporal and spatial pervasiveness of the arguments about the role of sensible behaviour in urban governance regimes put forward in this book, as well as the entrenched and intractable nature of the risks associated with diet, sedentarism and drinking. In the US, Barack Obama has toiled to push health up the agenda, passing the landmark health care reform bill through the Senate in early 2010 and has since faced constant threats from the Right to repeal these advances. His wife, Michelle, has championed the cause of childhood obesity prevention through the Let’s Move! programme and the transformation of a part of the White House lawn into a community garden. Yet, despite these efforts, preventing obesity, encouraging greater physical activity and moderating alcohol intake remain what Hunter (2009: 202) has pertinently described as ‘wicked issues’, or those which have ‘complex causes and require complex solutions’. The discussions that have unfolded in this book have spanned the Atlantic and a five-year time period. They have also clearly illustrated this complexity as well as the intractability of the ‘wicked’ and the clear need to interrogate the variegated politicisations and problematisations of health. However, and as Hunter further identifies, the persistence of these wicked issues remains a facet of government ‘preferring to regard such problems as being ones of individual lifestyle rather than being socially and structurally determined’ (2009: 203). The inevitable result of this way of thinking is ‘always to direct interventions to changing individual lifestyle rather than to reducing the health gap between social groups’ (ibid). It is clear that as long as this oversight remains, then wicked issues will remain just so.
On both sides of the Atlantic, therefore, the debate over where the lines of responsibility should be drawn for health and ensuring the uptake of healthy lifestyles continues with little sign of resolution. The fact that this debate is so enduring gives an indication of the disjuncture between the outward simplicity of healthy lifestyle messaging (eat more fruit and vegetables, move more, drink less alcohol) and the pervasive complexity of defining, delineating and communicating what it is to be sensible and, moreover, encouraging the uptake of such behaviours. In large part, it is possible that this disjuncture is so entrenched because being sensible in contemporary neoliberal societies has come (p.206) to symbolise far more than just health. Indeed, as this book has argued, sensible behaviour exists as both a spatial and a social strategic tool or ‘fix’ for some of the core tensions in neoliberalism, while also ensuring that its negative externalities can be transmogrified from risks to innovative market opportunities. Thus, in placing great expectation on the possibility and plausibility of being sensible and the host of commercial opportunities that these generate (such as advances in the leisure and fitness industry, new bar designs and formats and ‘healthier’ food choices), there is a danger that addressing the structural causes of poor health becomes overlooked in favour of providing new consumption solutions couched in the justificatory language of choice. For example, while MPREs offer a motivational route to increased participation in exercise, they do nothing to address the environmental barriers to activity at a city or local level. Moreover, their 12-week ‘communication plan’ offers little more than a temporary fix and is not tied in any way to the promotion of local sports facilities or clubs. This represents a real missed opportunity for the health promotion agenda. In this brief conclusion, the three core contentions of this book will be revisited, before we dwell in greater detail on the key findings and significance of this work through a critical reflection on the comparisons and contrasts between the empirical examples discussed.
Revisiting the three contentions
This book has centred on three core contentions that, in turn, have been critically examined through a series of empirical examples and case studies. In the first instance, it has argued that there needs to be far greater attention paid to the relative influence of ‘luck’ on responsibility and informed choice and, therefore, the plausibility of adopting sensible behaviour. In turn, the influence and significance of individual and geographical luck also demands further exploration. The operationalisation of informed choice and personal responsibility in neoliberal rhetoric, policy and practice is frequently communicated through the language, categorisation and expectation of sensible behaviour. Yet, despite semantic suggestions to the contrary, sensibleness is a dynamic and thoroughly malleable category, the definition of which has long mirrored social and political aspirations and fears. However, sensible behaviour does not exist extraneous to individual and collective luck and its expectation runs the risk of over-emphasising personal capacity for exercising the appropriate and necessary degree of responsibility and persistently underplaying the individual circumstances that may impede its realisation. The resultant culture of blame does nothing to improve health outcomes or the places that condition them.
In order to explore this contention, Chapter Two examined the centrality of informed choice and personal responsibility in neoliberal ideology, with a particular focus on the ascent of New Labour’s public service reform Choice Agenda (Jordan 2006) and mounting political concern with individual lifestyle as risk. The neoliberal ideology of ‘personalisation’ (of state services) and ‘responsibilisation’ (p.207) (of the self in relation to such services and fellow citizens), cast at an individual level, does not, however, sit easily with a perspective of social determinants of health that views health as patterned at broader, structural levels (Marmot 2005). The focus on personal responsibility assumes the existence of choice and yet, when such choices are patterned in ways that evade individual control there needs to be greater appreciation of the role of individual circumstance or luck in determining health outcomes. Under the present financial circumstances and particularly as medical services begin to be rationed in the NHS, moral ascriptions of responsibility and choice are only likely to increase in significance. Thus, attention to personal and geographical luck (or the fate of birthplace) is of central importance when arguing for behaviour change and the adoption of healthy lifestyles. Some places, as this book has shown, do not always enable true choice. Sometimes choices do exist, but rather the problem remains the assumption by those governing that the ‘wrong’ choices will be made by a culturally stereotyped population. This conflation of the spatial and the cultural was certainly the case in East Austin in attempts to prevent and manage obesity, but also has a strong presence in discourses of youth drinking in London. Risk, responsibility, choice and luck are complex moral and practical terrains, but often these categories become elided in the minds of those ‘control workers’ interviewed for this book. As a result, stereotyping of health behaviours is rampant and was often found to guide policy practice to a far greater degree than the use of baseline data.
The second contention for which this book argues concerns ways in which sensible behaviour has emerged as a strategic tool for the reconciliation of tensions inherent in neoliberal societies and economies. In effect, being sensible or the ‘ordered obedience of the desired subjects of civic culture’ (Miller 1993: xi) enables the consumption of self-control. Consumption is absolutely essential to the growth of the neoliberal economy, while self-control acts as a form of risk mitigation in a landscape across which risks are pervasive and can be pernicious. In order to manage these risks, the neoliberal subject must constantly balance three sets of elements: the urge for self-indulgence with the need for self-restraint; the promise of freedom with the persistence and necessity of coercion; and the realms of supply and demand. The examples discussed here demonstrate the dialectical relationships at work between these categories and, in the acts of their governance, in bringing them to some kind of resolution. Being prudent and, in the case of diet, exercise and alcohol, pursuing moderation (although more exercise is preferable for the majority of people) is, somewhat ironically, now also a huge market opportunity. This is less surprising when it is considered how poor health is routinely figured as a problem of incorrect supply (as well as irresponsible demand). To thus commodify sensible behaviour in the shape of new ‘healthier’ food products, the constantly evolving gym and leisure industry (Smith Maguire 2008) or through new bar and pub formats seems a logical market response to accusations of supply-side irresponsibility on the part of industry. However, simply ensuring supply does not guarantee demand, even when choice is touted as the rhetorical backbone of lifestyle.
(p.208) The third contention that underpins this book argues that encouraging sensible behaviours with respect to healthy lifestyles exhibits a spatial logic and spatialising tendencies that extend far beyond public health and into, for example, the realms of urban planning, crime and disorder reduction, social inclusion agendas and urban regeneration. Indeed, such policies are indicative of a far wider turn to the spatial in both explaining and seeking solutions to public policy conundrums. However, the examples discussed here clearly demonstrate the limitations to the uptake and realisation of this spatial logic, despite its clear conceptual value and ethical significance when considered alongside the role of individual and geographical luck in health outcomes. Eliding the language and epistemology of behavioural and cultural change with framework of environmental determinants of health fundamentally reorientates the ways in which individuals and communities are called to task for their own health. This is primarily because of the limitations to divining causal influences on health at a variety of scales (for example individual, family, neighbourhood, city) and, therefore, delineating the most appropriate policy orientations and productive distribution of resources. Thus, with the built environment increasingly being cast in instrumental terms as a ‘tool’ for the realisation of this broad range of social policy objectives, exploring the problematics of public health therefore also comes to stand as a metonym for a host of broader urban issues and reflective of concerns and fears over the contemporary urban condition.
Chapter Three explores this re-spatialised public health, arguing that this mode of thinking engages health in complex dialectical interactions with environments (understood as an interlacing of built form, culture and political economy). In other words, in examining the intricacies of contemporary debates in public health on the ground, this book also explores how urban liveability (in its broadest sense) is now also being governed ‘in the name of health’. Thus Gesler and Kearns (2002) assert, health is both a powerful metaphor and one that ‘can steer place-making activities’ (Geores 1998: 52). As such, and in recognition of Petersen and Lupton’s (1996) call for greater attention to the political strategies deployed in the name of advancing the ‘healthy city’, Chapter Three also makes a case for the series of city-focused case studies that form the empirical core of this book. Yet, the interactions between urban spaces and public health exigencies exhibit marked variations depending on the lifestyle behaviour in question. For example, the urban politics of sensible drinking are far more politically entrenched in the UK than are those of obesity risk reduction, principally due to the ways in which drinking is repeatedly framed as an issue of crime and disorder rather than health (Herrick 2010). Problematisations of drinking among those interviewed thus exhibited strong geographical imaginations of cause and consequence. While those engaged in preventing obesity and encouraging sport also had a certain awareness of the salience of the spatial, the construction of policy priorities (targets) allowed little room to think through ways in which geographical risks might be managed or mitigated. As such, all three ‘diseases of comfort’ discussed in this book shed light on an array of conceptual and pragmatic limits to managing city environments (p.209) in the name of health (Peterson and Lupton 1996: 136), where certain ‘ecologies’ (or ecological niches) are inherently more pathogenic or risky than others.
The governmental enterprise of encouraging and eliciting sensible behaviour among its citizenry has the hypothetical triple goal of creating better health, better places and better people. However, in reality and as the research discussed throughout this book shows, those engaged in developing and deploying policies or shaping the parameters of health debates often have a very limited appreciation of the spatial, despite the geographical referents and imaginaries included in an increasing array of government policy documents (see for example Department of Communities and Local Government 2007; Sport England 2008; Department for Communities and Local Government 2009; National Institute for Health and Clinical Excellence 2009; Lee et al 2010). This pervasive disjuncture between policy and practice represents a consistent impediment to heath improvement in all the cities discussed in this book. Crucially, this book is novel for exploring these limitations, inconsistencies and consequences of risk mitigation logic and strategies in situ and, in so doing, critically interrogating the lines of similarity and different between eating, exercising and drinking as risky behaviours. Such questions are exceptionally important for two reasons. First, eating habits, sedentarism and drinking in aggregate make up lifestyle and, therefore, risk. As such, disentangling causality and the relative effects of certain behaviours is virtually impossible (for example, might type 2 diabetes be primarily caused by elevated body mass as a result of excess calories or insufficient exercise?) However, the interlocked nature of these risks does not quash attempts to quantify and separate their causal influence on mortality and morbidity and, therefore, economic costs of all three behaviours, even as the methodologies used to do so (for example risk attributable or aetiologic fractions in the case of obesity) have been subject to huge criticism (Mokdad et al 2004; Couzin 2005; Mark 2005; Herrick 2007).
Second, there is limited evidence of best practice for preventing obesity, encouraging physical activity uptake and moderating drinking. Thus, with evidence-based policy the gold standard but with evidence scarce, there have been concerted efforts to learn from and draw parallels with other risky health behaviours and the tactics and techniques of their associated industries. For example, there have been concerted efforts to think through the commonalities between the history of effective tobacco control and the relative inertia of efforts to prevent obesity (Chopra and Darnton-Hill 2004) and to encourage moderate drinking (Bond and Daube 2009; Bond et al 2010). Of particular concern have been the tactics of Big Tobacco, Big Food and Big Booze respectively, and tracing the history of tobacco companies’ promotional and regulation-evading strategies as a potential predictor for the future tactics of the food and alcohol industries. This insight is especially important given the political currency such companies hold as major contributors to national duty and tax income, and as large-scale employers as well as sitting on government advisory boards (the coalition’s Responsibility Deals being a clear case in point here). Moreover, such comparisons are also useful for what they show about the relative efficacy of demand-side versus supply-side (p.210) strategies for encouraging sensible behaviour and for the ways in which demand-side explanations of behaviour are often used as a convenient foil for protecting against increased regulation of supply such as the minimum pricing of alcohol or fat taxes, despite ardent calls to regulate supply by the public health lobby.
Eating, exercising and drinking: overlapping and discrete lifestyle risks
The discourse of ‘healthy lifestyles’ often elides quantitatively and qualitatively different behaviours. As a counter to this tendency, this book has brought together those behavioural realms that are too often considered as conceptually distinct issues or, famously in the case of alcohol, as ‘no ordinary commodity’ (Babor et al 2003). This assertion is immediately problematic as the risks discussed here are so potent because and not in spite of their ordinariness. As part of everyday, ordinary life, eating, exercising and drinking test the boundaries of choice and responsibility in markedly different ways. For example, individuals can, realistically, rarely exercise too much (although there are clear instances where this can happen in conjunction with eating disorders), and even gentle exercise is better than no exercise at all. However, the messaging for eating and drinking is more complex as it involves asking people to ‘moderate’ (usually reduce) their consumption and therefore remains open to wilful and self-serving interpretation. As Chapter Seven argues, the long-standing debate over units and risk thresholds for alcohol in the UK demonstrates very clearly the difficulties in deciding not just the levels at which risks lie, but also the degree to which such advice is likely to be socially and politically sanctioned. Despite their centrality to the direction taken by health policy, there has been far too little attention paid to the importance and dynamics of these sanctioning processes in urban environments. In response to this deficit, the research that underpins this book has uncovered some particularly interesting findings concerning the social and political negotiations over meanings that go into health promotion activities. In short, how a problem is framed will guide its likely solution. In this case, eating, drinking and exercise are framed in quite different ways for different risk groups in different locales.
This research has further revealed the dynamic and fleeting nature of health concerns. To clarify: a number of historical works have clearly shown the ebbs and flows of social and political concern with corporeal fatness (Schwartz 1986; Stearns 1997) over the last century. National fitness levels have been of episodic concern since John F. Kennedy’s Cold War call to arms in the ‘The soft American’ (1960). In this he evocatively stated that ‘the physical vigor of our citizens is one of America’s most precious resources’ and if this was to ‘dwindle and grow soft’ then America would be ‘unable to realize [its] full potential as a nation’. Interestingly, this nationalistic concern with sports participation also mirrors the kind of language now being used to describe popular fears over the UK’s levels of alcohol consumption vis-à-vis other (supposedly more disciplined) countries. While there is also a long history of concern with drinking (Kneale 1999; (p.211) Berridge 2005, 2006; Herring et al 2008a), it is only in recent years that data on consumption levels and trends has allowed for international comparisons. As Chapter Seven discussed, the assertion that the UK has the ‘worst’ drinking habits in Europe (NHS Confederation 2010) has realigned the alcohol-control debate in more geographically comparative terms. However, over the shorter time scales explored in this research, interest in such risk behaviours often shifts according to the funding and ideological priorities of government. These shifts, while often temporary, are rarely innocuous.
In the case of obesity, for example, such a situation was found in both London and Austin. Even in the time between my two visits to Austin in 2005 to 2006, there was a palpable sense of disappointment that the energy and enthusiasm so clear in 2005 had not been harnessed into any concrete and concerted city-wide action to prevent further rises in obesity. One interviewee aptly summed up this sentiment when he said “it feels a little like fatigue, fat fatigue … The interest in it is there, but not as fanatical as it was” (TDHHS, interview, 2006). Another interviewee also corroborated this malaise with the suggestion that, “the media spotlight has waned, the attention, the obsession, has gone onto other things” (PR and media, interview, 2006). While those in public health and the voluntary and community sector in both Austin and London were exceptionally keen to exploit political momentum around obesity prevention, it was often the case that short-term funding streams (that is, the money from Choosing Health) would often only pay for someone to be in post for a couple of years to oversee, for example, a PCT’s obesity strategy. This was also the case for funding posts around alcohol harm reduction and in sports promotion. Thus, while the historical accounts discussed here suggest some degree of continuity in social attitudes towards health risks, the empirical research demonstrates a temporal mismatch in governmental commitment. In spite of the tone of David Cameron’s Big Society thesis, coordinated heath action needs money. When this is short lived, or the conditions attached to it have a propensity to change suddenly (as in the sudden shift from a concern with women’s health to men as a more significant health risk group in the UK), then health promotion and risk reduction work suffers.
As this book has shown, there are clear practical and financial constraints to shaping individual and population health behaviours in more sensible ways. However, the arguments made to justify differing resource allocations also highlight the varying ways in which each of the behaviours discussed here contributes to or risks the diminution of ‘the good life’ or ‘wellbeing’. This is particularly the case as ‘individualized freedom of choice can undermine social attempts to consider appropriate levels of consumption’ (Hanlon et al 2010: 310). It is this tension between individual wants and social needs that so often undermines the pursuit of the good life. The split between the desire to grant and take advantage of freedom and the need to set boundaries based on risk calculations is evident in all the case studies. However, the risk calculations are constantly contested, often contradictory, subject to international variations and often communicated in ways that leave the consumer either bemused or (p.212) determined to reinterpret risk thresholds in a manner that gels more neatly with prevailing social norms. This is particularly the case with regards to the self-denial and short-term risk calculations that so often accompany drinking, but is also plainly evident in the mismatch between high awareness levels of guidelines such as ‘five a day’ and relatively low consumption rates of fruit and vegetables. The exceptionally slow rises in sports participation despite financial investment, clear government interest and continual advances in the political economy of leisure is also testament to the creative and self-legitimising inertia of many consumers. To be sensible is thus to be torn between the consumption habits that are the right of freedom and the constraint that is needed to skirt the threat of coercion that so often hangs heavily and uneasily over neoliberal societies.
Is there a way forward?
It is not the goal of this book to offer a list of definitive policy recommendations. Instead, it would seem fitting to ask what lessons can be learned from bringing together this set of health risks across a number of case study sites. These, it is argued, are fivefold. First, while eating, drinking and exercise are considered separately in this book, they also need to be theorised in tandem. Such thinking is antithetical to governmental agenda and priority setting (which most often proceeds in strategies defined by health risk), but it is only in seeing these risks as mutually reinforcing that these practices might start to incorporate broader conceptions of wellbeing that might also expand discussions to include environmental modifications, rather than simply focusing on narrowly measured indicators of individual health (such as BMI).
Second, any examination of health, as Wilkinson (2005) reminds us, sheds light on the problems with place. In so doing, it also offers up some idea about the ways in which places might be improved in order to influence health outcomes positively. While the research found a keen awareness of the influence of place on health among some interviewees, it was more often the case that targets (for example NI8 for sports participation) tended to focus on individual outcomes rather than on removing the structural barriers to behaviour change and thereby addressing certain social determinants of health. What was so often missing was a genuine desire to redesign quality environments and places, despite such spatial aspirations being of core importance to the original aspirations of public health (MacKian et al 2003) and an increasing prevalence of design guidelines for more active communities. Poor health demands a geographical resolution. The current concern with healthy lifestyles represents a huge opportunity to mobilise resources and momentum behind creating better places. So far, these efforts have been far too limited.
Third, the actions of a few influential individuals can often have more impact than the actions of many. This was clear in both Austin and Newcastle, where the business interests of Paul Carrozza and Brendan Foster respectively have been productively and profitably interwoven with public health concerns. While the (p.213) impact of MPREs on longer-term sports participation is clearly dubious and in need of far more research – the influence of their champions is marked. This ‘go-getting’ spirit is something to be harnessed rather than dismissed. Those in Austin were able to do this through Paul Carrozza’s role on the Governor’s Council. However, the inability of those in Newcastle to harness the resources and influence of Foster’s company remained a profound source of frustration, especially given the clear value that would be derived from any collaborative effort.
Fourth, private and public sector roles in health are becoming increasingly blurred, especially as corporate social responsibility agendas allow industry to enter the realm of health promotion. This is not necessarily of concern in itself, but rather for the ways in which it problematises the contractual relationship between the state and individuals that forms the bedrock of admonitions to be sensible. This blurring is symptomatic of the changing nature of health information and advice which is now overwhelmingly to be found online rather than in medical settings, but it is also indicative of the changing direction of public trust as well as the permeation of health agendas into a host of other political policy arenas. In short, while individuals might once have looked to the state to ensure their right to good health, this orientation is increasingly taking in the private and voluntary and community sectors. While the irony of companies such as Nestlé or Kraft promoting healthy lifestyles may seem ironic, the resources that they bring and their capacity to fund research present perhaps the greatest threat to the public sector’s hold on health promotion. There thus needs to be greater critical exploration of these shifts rather than their dismissal if health promotion is to avoid being hijacked and commodified.
This leads to the fifth and final point; more research is needed that critically interrogates the relationships between political economy and health behaviours. For many in public health, ‘industry’ is a dirty word, and the bitter taste left by the business practices and legacies of Big Tobacco has understandably lingered. Moreover, in seeking to second guess the future tactics of the food and drink industries, some sight has been lost of the role played by consumer demand in creating health risks. While supply is a significant element of the genesis of risk, it is only one part of the political economic contract. It is clear that demand is infinitely malleable. However, consumer demands are also symptomatic of the kind of discordant interactions between self and environment that this book has discussed. In other words, consumer demands often express a profound individual or group need; they also clearly exemplify specific sites of societal anxiety where self-efficacy is persistently absent. One clear example is the socially normative assumption that an alcoholic drink will bolster confidence and sexual attractiveness on a night out. The UK government has tried to discredit this with its ‘Know your Limits’ campaign, in which the consequences of a drunken night out are replayed in reverse to the viewer from finish to start with the strapline, ‘You wouldn’t start a night like this, so why end it this way?’ However, we still have insufficient knowledge of the contextualising processes that make definition of risk thresholds socially resonant. This is a crucial knowledge deficit, especially given the ongoing (p.214) work of industry to reframe biomedical research, shape the ensuing debates and, therefore, fundamentally alter the processes of contextualisation that serve to legitimise certain risk-taking behaviours. For these reasons, future research needs to be attuned to the politicisations of the political economic and the significance of these processes for the dynamic interactions of supply and demand.
Osborne suggests that the concept of health possesses both an ‘essential elasticity’ and ‘indeterminacy’ and that, for this reason, ‘health cannot be associated with normality, but only with normativity, with the capacity to impose new norms’ (1997: 180). As he further asserts, when political attempts are made to ‘absolutise’ or ‘make determinate’ the concept of health, then health itself is transformed from a right to a duty of citizenship. In all the examples discussed in this book, health sits – albeit in various ways and to varying degrees – at the fulcrum of right and duty. This is especially the case given that the health risks under consideration often arise through legitimate and socially sanctioned consumption norms. Yet, when health becomes a necessary duty in order to qualify for treatment, as is increasingly becoming the case in the resource-starved NHS, then these risky consumption practices may need not just to be questioned but also restricted. To do so would require the brave and exceptionally unpopular move of regulating choice and, as a result, diminishing certain freedoms. A clear example would be addressing the supply of alcohol through minimum pricing in the UK. This would seem to offer a way to work with consumers’ immediate cost aversions in order to reorientate the popular view of alcohol from disposable, cheap commodity to one with greater social value. That this would penalise the ‘responsible majority’ then depends on how the term ‘penalty’ is defined and understood. If moderation is the goal, then there is no financial penalty to be had from consuming less alcohol at a higher price. However, if pleasure through freedom is the goal, then any restriction can rightly be construed as penalty. But, with affluent societies irrecoverably divided along socioeconomic and ethnic lines, freedom of consumption is already a misnomer. Consumption habits are fickle and liable to rapid change, yet the geographies of threat and opportunity that so often pattern health behaviours are deeply rooted. It is these roots that need prompt excavation if we are to forge not just healthier people, but also better places.