Health Psychology. Michael Murray
Facts of Life and Death
Where a baby is born and the mother’s access to water, food and education determine whether the baby lives or dies. A baby in Sierra Leone has a 72% chance, while a Japanese baby has a 96% chance of reaching the age of 5. Health inequalities have always existed; in this chapter, we examine why.
Each individual human is a creation of genetics, environmental experience and the interaction between the two (see Chapter 3). The environment can be broken down into macro and micro levels. The macro-social environment affects health and well-being in a huge variety of ways. The term macro-social refers to large-scale social, economic, political and cultural forces that influence the life course of masses of people simultaneously. Macro-social influences include actions and policies of governmental organizations, non-governmental organizations (NGOs), cultures, historical legacies, organized religions, multinational corporations and banks, and unpredictable, large-scale environmental events, all of which have the potential to influence huge sectors of the entire human race.
First, devastating ‘acts of God’ can have severe consequences for individuals and communities. The short- and long-term health impacts of these events are moderated by international readiness to respond, and Interdisciplinary Emergency Response Teams can ameliorate the impact of natural disaster and extreme weather events. Microblogging on Twitter and other social media is helpful in expediting rapid disaster response (Tapia et al., 2013).
Second, a variety of pandemics that spread across continents include typhoid, cholera, avian flu (Shinya et al., 2006), influenza (Karademas et al., 2013; Mo and Lau, 2014; Flowers et al., 2016), COVID-19 (Matias, Dominski, & Marks, 2020) and HIV infection (Pellowski et al., 2013; Rohleder, 2016).
Third, the scourges of war, genocide, sectarian violence and terrorism take a significant toll, with multiple deaths, injuries and trauma (De Jong and Kleber, 2007; Medeiros, 2007; Ciccone et al., 2008; Maguen et al., 2010; Zerach et al., 2013).
Fourth, the legacies of colonial genocide take centuries to heal. Indigenous ‘First Nation’ communities have consistently disproportionate rates of psychiatric distress that are associated with historical experiences of European colonization (Gone, 2013). Aboriginal children experience a greater burden of ill health compared with other children, and these health inequities have persisted for hundreds of years (Greenwood and de Leeuw, 2012).
Fifth, human recklessness with fossil fuels is causing global warming, climate change, rising sea temperatures, acid rain, coral bleaching, global dimming, ozone depletion, biodiversity loss and rising water levels, all transforming life on this planet as we know it (Pearce, 2009).
Sixth, the use of fossil fuels is peaking and, as oil and gas reserves run out, have become more costly; the world economy could go into decline, with significantly decreased agriculture and food production (Murphy and Hall, 2011; Pfeiffer, 2013).
Seventh, increasing poverty makes life a struggle for survival for a billion people. In spite of progress, almost 870 million people were chronically undernourished in 2010–12, the majority living in developing countries, where 850 million people, or 15% of the population, were estimated to be undernourished (Food and Agriculture Orgwanization, 2012).
Eighth, lack of clean drinking water is a major cause of suffering, disease and early deaths: 3.4 million people die each year from a water-related disease, with 780 million people lacking access to clean drinking water; 2.5 billion people have no access to a toilet (water.org, 2014: http://bit.ly/1aa4eri).
The message of this chapter is summarized thus: what individuals can do to change their lives is not simply a matter of personal choice – such changes are constrained politically, economically and culturally. In the globalized economy, everything is interconnected. Macro-social economic, political and cultural factors create the context for everything else, including health, illness and health care.
Policy, Ideology and Discourse
The dominant discourse within neoliberal health policy has been that of the autonomous individual, in which each individual is an agent, responsible for his/her own health. The ideology of individualism dictates that each person is motivated by self-interest to elevate his/her well- being with the least effort and resources possible. Deep within the ideological substratum of modern culture lurks the credo of individualism – ‘each man for himself’ – making his/her choices, and taking the consequences, as in: ‘You made your bed, now lie in it.’ Theories in health psychology are imbued with this cultural presumption. The existential truth of ‘do or die’ is embellished in polite language as ‘making informed choices’.
The cult of the individual has spawned the notion of the responsible consumer (RC). The RC is an active processor of information and knowledge concerning health and illness. He/she makes rational decisions and responsible choices to optimize well-being. The epitome of the RC is the hypothecated ‘anything in moderation’ person who eats five-a-day, never smokes, drinks alcohol in moderation, exercises vigorously for at least 30 minutes three times a week, always uses a condom when having sex, and sleeps eight hours a day. The stereotype of the more common ‘irresponsible consumer’ (IC) is the so-called ‘couch potato’ who enjoys beer and cola, smokes, eats junk food, watches TV for many hours each day, and rarely takes exercise. Accordingly, responsibility for illness relating to personal lifestyle is seen as the fault of the individual, not an inevitable facet of a social, corporate, economic environment designed to maximize shareholder profits.
Using a mixture of well-intentioned pleading, information and advice, the traditional approach to health education aimed to persuade people to change their habits and lifestyles. Information campaigns designed to sway consumers into healthier living were the order of the day. Combined with policy and taxation, health education justifiably can claim some limited success over the last 50 years, e.g., the fall in lung cancer rates. Tobacco control has become a benchmark for what may be achieved through consistent public policy, educational campaigns and behaviour change. A major public health call today is for a vigorous campaign to halt the obesity epidemic. If similar methods are deployed to those used for tobacco (i.e., voluntary controls, advertising restrictions, product labelling, health education), then the evidence suggests that it could take at least 50–70 years before obesity rates can be expected to go into any noticeable decline (Marks, 2016b).
In recent decades, appealing to the right-minded ‘anything in moderation’ consumer has been prevalent throughout health care. The prescription to live well has always had a distinctively moral tone. Health promotion policy has been portrayed as a quasi-religious quest, a war against the deadly old sins of gluttony, laziness and lust. Discourse analysis of public health policy statements makes this fact all too clear (Sykes et al., 2004).
The demise of the construct of the RC is imminent within health policy. Common observation and decades of research show that people are really pushed and pulled in different directions while exercising their ‘freedom of choice’. Emotions and feelings are as important in making choices as cognition. The beneficial satisfaction of needs and wants must be balanced against perceived risks and costs. Health policy is beginning to acknowledge both the complexity of health and the power of the market. Human activity is a reflection of the physical, psychosocial and economic environment. The built environment, the sum total of objects placed in the natural world, dramatically influences health. The ‘toxic environment’ propels people towards unhealthy behaviours, directly causing mortality and illness (Brownell and Fairburn, 1995).
Government policy documents in the UK indicate that the reliance on consumers as responsible decision-makers has been waning, but it remains a primary strategy. The environment and corporations are being given a larger role. In Healthy Lives, Healthy People: Our Strategy for Public Health in England (Department of Health, 2010: 29), the government stated:
2.29 Few of us consciously choose ‘good’ or ‘bad’ health. We all make personal choices about how we live and behave: what to eat, what to drink and how active to