Myth #3: Causes of Ill Health are Physical and Personal

By now I have just about hammered home the point that, as a general principle, the health profession looks for causes that are physical and tied to the individual. This approach has led so many in the field to focus on diet (fat, cholesterol, salt; now carbs, transfats, etc.), personal habits (how much do you exercise, how long do you sleep, how much do you smoke, how many sexual partners do you have...), family medical history (in so far as "the family" represents a personal gene pool), exposure to disease causing agents, and the like.

On the contrary, emotional, social, political, and economic causes of disease are given secondary consideration, if any at all.

I remember reading Malcom Gladwell's book Outlier, which begins with the story of an American immigrant community who presented phenomenally low levels of heart disease. Gladwell recounts the investigative process undertaken by medical rsearchers to determine the cause of this felicitous situation, including all the many dead-ends and their ultimate conclusions. I found the discussion fascinating and began describing the scenario to my mother. Immediately, she began throwing out possible explanations, in pretty much the same order as the medical investigators considered them. "It must have been their mediterranean diet" (no, they had switched to a high-fat, high-carb diet). "They must have walked frequently and performed a lot of physical labor" (not a chance). etc. etc. What never occurred to my mother, and in fact, what only occurred to the researchers after they had pretty much exhausted all other possibilities was this: the community had very tight social bonds and spent a lot of quality time together, they regularly participated in religious activities, and they exhibited a general sense of emotional well-being. Is it possible that happiness, strong social relationships, and spirituality may promote health more than diet and exercise?

In Myth #2 I discussed the role played by inflammation in such conditions as high blood pressure and heart disease. This raises the possibility that stress is more of a "root cause" of these maladies than diet, exercise, and other personal habits. It would follow that the promotion of personal, social, and spiritual well-being may be a more effective way to nurture one's physical health than avoiding salt or constantly striving to lose 10 pounds. However, interventions aimed at the individual are easier to implement and control, and are infinitely more profitable.

Another example. It is often suggested that people with less money are more likely to be fat because healthier foods are more expensive. If you have a limited budget and work two jobs, then McDonald's is going to seem like a much more attractive option. This is a great argument for those who prefer to view health in terms of personal responsibility. It is the choices poor people are making (even if their options are limited) that cause them to be fat.

Yet, it is also true that living below the poverty line is significantly more stressful than living above it, and in the case of classic urban poverty, it generally entails fractured familial relationships and impoverished communal bonds. Could the political economic processes that create conditions of poverty be responsible for obesity among the poor? Is it more than simply a matter of the food they buy?

Similarly, a lot of noise is made about how African Amercians are "naturally" predisposed to high blood pressure, heart disease, diabetes, etc. This "medical fact" is convenient in two ways: not only does it locate the cause of these diseases in personal defects, it also sustains ideas about racial difference! How nice. Once again, we must consider: 1. African Americans are more likely to be poor (go back to above paragraph) 2. African Americans have to deal with racism, which is another significant stressor. Some medical researchers, in fact, have argued that the African American "predisposition" to high blood pressure is really caused by racism.

In the above cases, emotional status, social relationships, and political economic conditions are intertwined. It should also be underscored that in some instances political economic circumstances may play an even more direct role in health. Another book provides an example.

In Stories in the Time of Cholera, Charles and Clara Briggs recount their experiences with an epidemic of cholera that swept through a portion of Venezuela, and analyze the way in which this epidemic was represented by the media and government officials as eminating from a coastal indigenous population, as a result of their "primitive" behaviors. Yet, the Briggs' describe how cholera is a distinctly modern phenomenon, in fact, nurtured by particular forms of political oppression, marginalization, and economic alienation that have been instrumental to processes of state-making and market formation during the capitalist era.

Taking the same stance, physician-anthropologist Paul Farmer argues in Pathologies of Power that disease has distinct social, political, and economic causes which are very often ignored.  In order to legitimate the current world system, these factors must be ignored, because they represent a challenge to the status quo.  On the other hand, focusing on individual habits (particularly those labed "premodern" and "primitive") in the promotion of health is an important means of constructing the narrative of Progress that makes the desirability of the current state of affairs seem unquestionable.

Capitalism and Health

I decided that I wanted to devote a number of posts to the subject of health.  The way we view and act upon the human body is a concern of central political, economic, and social importance, as well as instrumental to the way in which we perceive ourselves as individuals.  To start, I will provide an overview of the capitalist approach to health that has become so pervasive and naturalized.

This approach entails the following assumptions:

1. It is the "normal" state of affairs to be "healthy." Thus, ill health and other physical maladies are a form of deviance.

2. Deviance comes in discrete packages: "disease," "infection," "syndrome," and "disability" are the most common. Each form of deviance, in turn, has a discrete and identifiable cause. Some causes represent inherent abnormality (genetic defects); some represent outside threats (bateria, viruses, fungi) which can be managed and prevented; and some derive from behavior. Furthermore, to the extent to which susceptibility to "outside threats" is determined by "inherent abnormality" and behavioral causes, its role is more that of a secondary cause.

3. Health is managed at the level of the individual, in terms of individual defects and behaviors. In this way, each individual often becomes directly culpible for his or her own health, and public health strategies focus on "education" and the management of behavior (encourage kids to exercise, regulate salt content, tax cigarettes, etc.). An ideology of "personal responsibility" and the employment of governmental power relations (two non-contradictory components of capitalism: both seeking to effect change at the level of the individual) are the name of the game.

4. Understanding of causation is extremely linear and material. A one-to-one correspondance is often sought between illness and personal hygiene, eating habits, level of physical activity, and engagement in "risky" (i.e. non-socially sanctioned) behaviors.

5. With discrete, material causes of health-related deviance, the restoration of "normality" may be pursued by equally discrete, material means: thus, the domain of health care is easily penetrated and transformed by capitalism and its tendency toward commodification of every possible aspect of life.

The following are some examples of the "simple math" that has characterized our approach to health:

-People with heart disease are often fat. Therefore, being fat must cause heart disease. Furthermore, you must be fat because you eat fat. Consequently, a low-fat diet will prevent heart disease. Oh, how convenient, now we have created a market for I Can't Believe It's Not Butter!

-If you have chest congestion and fatigue, you probably have a respiratory infection. Infections are caused by outside agents. Outside agents must be killed by antibiotics (because the human body is not designed to deal with bacteria and viruses on its own). Oh, how nice for the pharmaceutical companies, people are willing to pay lots of money for drugs! (Oh, too bad for the poor people who actually need them but can't afford them...)

-Syphillis is a sexually-transmitted infection. Since syphillis is a "deviant" condition, it must result from deviant sexual behavior. Therefore, only people who deserve to get syphillis get syphillis. Hey, why not use poor black people with syphillis for the unnecessary medical research that supports our gainful employment? If we treated them, we would only be shielding them from the consequences of their actions anyway.

-Everyone's body is, ideally, exactly the same. If someone's body deviates from this ideal, it must be their fault. They should live in constant guilt and shame. They also should spend an inordinate amount of time, energy and money trying to become closer to the ideal. Since practically nobody is "normal," what a large market that creates for diet products, exercise equipment, fancy scales, and magazines with helpful tips on how to "get the abs of your dreams" (or, just for Schadenfreude, investigations into which celebrities have gained 2 pounds)!