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  • Writer's pictureStephen Balogh

Public fitness then and now

I think I’m mischaracterising it somewhat, but school history in UK schools seems to be largely post-war only these days, with at best the Tudors thrown in as a relatively safe period to study (“safe” equals “unproblematic” here). The “start of history” is a subject I want to return to another time.

One episode from British history that is certainly not uncomplicated was the late nineteenth century Boer War. I am not planning here to write about that subject per se, but instead to refer to one of the commonplaces popularly associated with it, that is, the paucity of general health amongst the young British recruits that is seen as a major factor in the British army’s unexpectedly poor showing in battle.

This particular aspect is viewed as a direct contributory factor to the 1906 to 1914 Liberal government’s radical reforming agenda, including policy prescriptions aimed at transforming public health. Alongside the military shocks from the Boer War were systematic studies into poverty and public health by concerned philanthropists such as Charles Booth and Seebohm Rowntree, together amounting to a conclusive call to action. The result was a wide-ranging series of reforms aimed at transforming domestic and occupational conditions both economically and in public health terms.

It is probably slightly simplistic for me to put it this way, but I imagine one of the reasons this is a “safe” area of historical study is that poor individual health was almost always outside the ability of individuals to control, especially those from poorer backgrounds. They had virtually no agency and therefore no responsibility for their poor condition. And it leads to a “good news” story because something material and lasting was done to make things better.

Wind forward to today and a new debate about public health, especially in the light of the manifestly differential impact of coronavirus for people with pre-existing health conditions. There are unquestionably pockets of poverty still remaining in the United Kingdom, some considerable and some largely hidden from general view. But it is also the case that a much greater proportion of the population has agency over decisions affecting health, arising from better education and general awareness of health risks, better living and working conditions, better healthcare, a greater proportion of leisure time and access to health-based leisure facilities.

In contrast to the situation 120 years ago that had amounted to a rescue of public health for a whole swathe of unempowered people, the situation is much more mixed today. Public health messaging rightly has to be carefully devised and presented to make the distinction between a propensity towards poor health for reasons within a person’s reasonable control and for those outside their ability to influence, including a remaining measure of environmental factors such as air quality. Added to this is a vast change in freedom in lifestyle selection and a general aversion to what is often referred to as “shaming”.

So far, the UK government’s approach to coronavirus (in common with almost all governments) has broadly used the “all in it together” that is akin to the principle of “no pre-existing conditions” in many health insurance arrangements. Whatever the reason, if you fall ill with coronavirus, you will be given the same treatment and no judgement will be exercised on how you came to be susceptible to the disease.

However, examination of the state of public health will necessarily move up the agenda once more. Alongside such things as another boost to the sorts of messaging so strongly associated with the 2012 Olympics and its aftermath encouraging people to sports participation, regrettably with quite mixed results, there is likely to be another strand in public health messaging associated with lifestyle choices.

This is of course where it becomes fraught. To what extent is it generally correct to assert people’s agency when at the margin it is simply not universally true? When do public policies such as minimum alcohol pricing and “fat taxes” start to impinge on the liberty of those already making responsible choices? And when might targeted policy prescriptions be politically untenable because they would appear to single out particular groupings?

What is for sure is that there is a huge difference between the relatively uniform – if pervasive – nature of the early 20th century challenges and solutions and the much more complex considerations these days. We may not have a central objective of being ready for mass mobilisation of human capital for war, but instead there is much need for a capability in general fitness to rebuild the country and world economically and socially. Fitness both in mind and body.

This searching for consensus, especially with so many differing views about cause and effect, agency and victimisation, will inevitably lead to an inherently suboptimal outcome, but one that is nonetheless essential for our collective health in the long run.

Underlying all this is the notion of moral hazard, a well-established concept in ethics, economics and other branches of philosophy and social sciences. General awareness of this concept rose significantly in the aftermath of the 2008 financial crisis, with manifest risks being taken by financial institutions under the apprehension – mostly true – that governments would bail them out if things went wrong. Whilst nothing is quite black and white, such examples are relatively simple to frame compared to much more complex considerations around individual decision making as to lifestyles and behaviours and the risk of consequences to others and to society generally. The risks from moral hazard rise with the degree of freedom of action: perhaps that’s for another blog entry sometime or readers’ thoughts in the meantime.

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