Personal responsibility and public health

Personal responsibility and public health

 

1            industry loves this narrative. You have got to wonder why

Of note the harmful product industries are strongly in favour of personal responsibility. You can draw your own conclusions why this might be. Read 1) the history of tobacco control esp the write up of California and New York from Stanton Glantz in Tobacco Wars

 

2            It is a policy framing problem for public health that crosses political divides  

This has been one of the deep running rifts in what different camps think about what would be most effective in public policy for many generations

It is fair to say that the response to Wanless and Marmot 2010 (for eg Govt response to Wanless in 2004 (John Reid), The NHS Long Term Plan and Five year view, and many others) continued to focus on lifestyle, and within that individual lifestyle choice.

 

3            two examples – infection and obesity

In infectious disease contexts, the pandemic has reminded us that whilst much emphasis was given to people obeying the guidelines, we didn’t focus enough on the structural determinants in propagating chains of transmission.

We have ignored SSP reform at our peril, we have ignored low pay and insecure contracts (and thus the ability to isolate), over crowded housing. These have all contributed to what was once called “enduring transmission”.

Much of our exposure to COVID risk is not in our personal control. It requires a collective effort, and we know that one of the key levers to encourage people to manage their risk, is to appeal to the importance of that collective effort and the impact of our individual behaviours on others. A strategy that focus solely on managing personal risk will always be sub-optimal

 

Obesity. We all know we forever see headlines in the paper that people should take “personal responsibility”. A focus on individual responsibility is a failed policy in this area over decades. The approach gives the message to individuals “sort yourself out, and if you cant, you are greedy and lazy “ (HT @Profpaulgately).  

It is at best an ineffective policy or a deliberate policy of industry to frame problems in a way to maintain status quo (see literature on commercial determinants).

 

Hugely disproportionate coverage is given to solutions  oriented in individual behaviours, personal responsibility, often at the expense of changing the context in which people live. The evidence is crystal clear in many different spaces and areas that whilst interventions focused on behaviour change is important what really makes biggest impact, and is most equitable, is addressing the upstream context and environment in which that behaviour happens.

 

Yes of course I should take responsibility, but I don’t make choices in a vacuum. My choices are shaped by the environment I am in – with financial, marketing and other cues all the time. A focus on personal responsibility and individualism simply locks on ineffective and inequitable interventions, it will not help us level up.

 

Those on lowest income would spend 75% of their disposable weekly income to meet the healthy eating guidelines. How do you make healthy choices when there’s rent to pay? Hence a focus on enabling environments, addressing the root causes, often income and ability to pay not a focus on personal responsibility.

 

 

 

4            if you aren’t for this what ARE you for

The obvious counter challenge is - If we ARENT people to take personal responsibly what ARE we asking. Well one thing would be in this beautiful corollary that was put by to me "If the small number of people in power & privilege at every level of society discharge their “personal responsibility” towards common good better with clarity, courage & compassion, public health will improve faster than ever." (thanks Sakthi) 

Personal responsibility - It is necessary, but nowhere near sufficient. The whole narrative of personally responsibility is a poor policy framework for any substantial shift in public health

 

Its more complex than simple binary thing. And landing it as binary also does harm, focus on it does harm.

the whole thing skews peoples mind and attention to what is measurable not what it most important. That in itself does harm AND it isn’t the answer to the enormous gap in health outcomes. See Beyond 'Run, Knit and Relax'  (Neoliberalism itself is the problem (and MECC et al plays DIRECTLY into that space), and also see reimagining social determinants of health (“lifestyle drift” vs CDOH and SDOH / structural influences)

 

Personal responsibly and agency DO matter

Yes of course we would all want our decisions about their behaviour to not just be based on our appraisal of our own risk. This does neglect how our behaviour impacts on other people – directly (say infectious disease spread) and indirectly (demand on treatment services which are overloaded due to avoidable demand)

 

I am not arguing *against* agency, I am not arguing *against* approaches on empowerment of individuals and communities. It is enormously important. Both are easily outgunned by structural factors.

 

It is thus naïve to think we can then expect a strategy based on personal responsibility to be effective

 

As an eminent professor said to me – you can have all the agency in the world but it will be dwarfed by grinding poverty.