Proponents of modern day public health measures (especially those measures that seek to tackle ‘non-communicable diseases’ through ‘lifestyle interventions’ or ‘behaviour change’) will invariably describe their proposed policies as fair, equitable, justified and any number of other feel-good words; but almost without fail the word progressive will feature somewhere within the missive.
In fairness, the deployment of this word comes about in an atmosphere in which every area of public life, and any form of public policy- not matter how trivial or banal- must be seen to comply with the overarching progressive narrative.
But nonetheless, if public health policies are to be described as progressive then it is fair to examine their claim to be so, in further detail.
What then is meant by ‘progress’ in public health? Should we take it that to be progressive means that people are able to live longer as a result of the proposed policy? Or given rampant trend toward egalitarianism within academic public health (Thanks in large to Marmot, Wilkinson and Pickett) does progress mean that policy will reduce health inequalities (perhaps through the use the marvelously paradoxical proportionate universalism as proposed by the Marmot Review?) Or should we consider fiscally regressive measures such as sugary drinks taxes to be progressive as they arguably reduce consumption of a product that has seemingly been ruled verboten?
That the concept of ‘progress’ must sit at the very core of public health policy stems from what I would argue is the skewed Weltanschauung of the public health community.
In this worldview, a policy is progressive if it extends lifespan, increases quality adjusted life years, diability-free life expectancy, reduces consumption of products/ingredients that are currently deemed unhealthy by the prevailing scientific consensus (Sugar? Fat?).
But what of those less tangible aspects of the human condition that don’t fit into the progressive worldview? Must public health policy only be considered progressive if it deifies diminishing time-preference (or declining concern for the present in comparison to the future)? After all countless philosophers, theologians, writers and sages throughout the ages have pointed out the folly and unhappiness that accompanies the wait for an imagined perfect future, rather than enjoying the present moment.
Perhaps the problem is best summed up by the phrase ‘immanentize the eschaton’. That is, public health policy often strives to make ‘heaven real on earth’ and fails to account for the inherent fragility of man (and all that actually being human entails). This clashes with those that would defend vices and ‘unhealthy’ behaviours and whose worldview is perhaps more inclined toward the human and romantic, rather than the scientific and rational (I would strongly emphasise that this is not necessarily a weakness!).
The inimitable observer of human life and foibles, G K Chesterton summed up this clash of worldviews perfectly; inveighing with his typical good humour against the obsessive progressivism of his ‘friendly enemy’ G B Shaw:
“After belabouring a great many people for a great many years for being unprogressive, Mr Shaw has discovered, with characteristic sense, that it is very doubtful whether any existing being with two legs can be progressive at all. Having come to doubt whether humanity can be combined with progress, most people, easily pleased, would have elected to abandon progress and remain with humanity. Mr Shaw, not being easily pleased, decides to throw over humanity with all its limitations and go in for progress for its own sake. If man, as we know him, is incapable of the philosophy of progress, Mr Shaw asks, not for a new kind of philosophy, but for a new kind of man. It is rather as if a nurse had tried a rather bitter food for some years on a baby, and on discovering that it was not suitable, should not throw away the food and ask for a new kind of food, but throw the baby out of the window and ask for a new baby.”
Chesterton’s words sum up this argument far better than I can. Whilst it remains important to try and improve public health, and to “look at the evidence”, I would argue that there is very strong case for public health to ‘remain with humanity’ and not let purely technocratic and progressive concerns override all others.
There are also cultural factors at play in this divergence of worldviews. When you are handsomely remunerated, intellectually stimulated by your work, cultured, intelligent and possess a social circle of equally well remunerated, educated and well-travelled peers- ‘lifestyle choices’ such as smoking, vaping, an unhealthy diet etc may seem derisory, unnecessary, inexplicable, disgusting even; but for those at the opposite end of the social scale they do not have the consolation of decent pay, stimulating and interesting work, and bourgeoisie leisure pursuits. Instead they turn to these ‘lifestyle choices’ despite (and sometimes because of) the detrimental impact on their long-term health outcomes. That these things are enjoyable and comforting is so often overlooked by those that do not indulge in them.
I’ll let a recently deceased Hobbesian philosopher bring this reflection to a suitably stark and blunt conclusion:
“Prior to the establishment of the state, life is nasty, brutish and short. Nothing changes once a state’s created. Only the longevity of the participant alters. And even that’s arbitrary.”