One of the central features of the new primary care White Paper is the plan to provide free medical check-ups.1 The Life Check programme aims ‘to help people — particularly at critical points in their lives — to assess their own risk of ill-health’, by focusing on ‘major risk factors’, such as obesity, smoking, binge drinking, mental illness and stress, and sexually-transmitted infections. The White Paper emphasises the role of education in promoting awareness of the risks of disease and of the measures deemed necessary to achieve and sustain health from infancy onwards.
But if health becomes the goal of life — as in the terms of the WHO definition ‘a state of complete physical, mental and social wellbeing’ — then it becomes an unattainable ideal, a state of perfection that may be striven for but never reached. From this perspective, health becomes exceptional — and illness, understood as the inevitable failure to achieve the ultimate goal, becomes normal. This new doctrine marks a dramatic break with tradition — but not a progressive one. In the recent past, health was regarded as the normal state of affairs and illness was considered an exceptional departure from normality, a transient state through which the patient passed — with the blessing of medical authority — before returning to a familiar level of social functioning.
Now health has become a state that can only be attained through a high level of personal awareness and commitment to a prescribed lifestyle, through intense vigilance against health risks and through a willingness to submit to regular professional intervention in the cause of preventing disease (or at least of detecting it at an early stage). At the same time, illness has lost much of its stigma and even confers a series of socially approved identities.
If health becomes the ultimate aspiration, then when individuals encounter setbacks and losses, these are likely to be experienced as forms of illness, which may well find expression in physical or psychological symptoms. ‘Doc, I just don't feel well’ is a familiar cry of existential distress in my surgery, uttered by ever-younger patients, and followed by the request, now endorsed by the government, for ‘a complete check-up’. According to the section of the White Paper on ‘mental health and emotional wellbeing’, ‘there is much that can be done’ to reduce not only ‘anxiety and depression’, but also ‘the widespread misery that does not reach the threshold for clinical diagnosis’. In fact, the ‘much that can be done’ amounts to little more than offering banalities about ‘eating well’ and ‘valuing yourself and others’. Yet, once the sphere of therapeutic intervention is expanded to include everyday misery, then illness has become the universal condition of humanity and health a utopian — if not a celestial — vision.
As health awareness has grown over the past two decades so, has illness. Surveys reveal that more and more people report feeling unwell, the numbers of people consulting their GPs and other health professionals (and alternative practitioners) have multiplied and levels of sickness absence from work have increased steadily.2 The intensive promotion of disease awareness fosters a climate of fear around issues of health, as people worry about their risks of succumbing to cancer or heart disease as a result of their deviant or merely deficient lifestyles.
Perhaps the most dramatic indicator of the rising tide of ill-health is the 2.7 million claiming incapacity benefit, nearly four times the level of 30 years ago. It is clear that the major explanation for this increase lies in the growth of conditions which are defined by the individual concerned and often cannot be verified by any doctor — or welfare bureaucrat. More than 1 million people, some 40% of the total, are claiming incapacity benefit with diagnoses of anxiety and depression and stress, a fourfold increase in 20 years. The second leading cause of sickness absence is back pain; numbers have increased steadily over recent decades and objective confirmation of subjective complaints is often impossible.
The government may try to curtail incapacity benefit but this will not deter the growth of illness resulting from wider cultural forces that its wider health promotion policies have done much to encourage.
- © British Journal of General Practice, 2006.