The Lancet, August 11, 2001 v358 i9280 p516

 The dangers of health promotion. (Brief Article)(Review)_(book review) Sally
Hargreaves.

The Tyranny of Health: Doctors and the Regulation of Lifestyle

      Michael Fitzpatrick. London: Routledge, 2001. [pound]9.99. Pp 196.
      ISBN 0415235723.

      "Patient: Will I live longer if I give  up alcohol and sex?
        Doctor: No, but it will seem like it."
       Cleare AJ, Wessely SC. BMJ 1997; 315: 1637-38

     We live in a time when there is an increased level of anxiety about being
healthy. An obsession that Michael
      Fitzpatrick believes is having a negative effect on many of his patients.
The "worried well", as he calls them,
      include anyone from a perfectly healthy person who demands a full medical
examination, to the many patients who
      seek medical check-ups as a result of an often exaggerated perceived risk
for some illness or other. Health has
      indeed assumed a high priority in our lives, and we now worry about
anything and everything: from sunbathing to
      sex, to the thickness of butter on our bread. Even so, it is hard to argue
 that the promotion of a healthier lifestyle
      can really be such a bad thing, and this is why Fitzpatrick's book is a
gem. As an author already accustomed to
      controversy, Fitzpatrick unravels a dark and alternative dimension to the
whole notion of health promotion.
      Government-led health promotional campaigns, he argues, are not perhaps as
 good for you as you might have
      thought.

     While the benefits of not smoking have been backed up by scientific
evidence ("the one aspect of health
      promotion for which there is a rational basis", claims Fitzpatrick), many
changes in lifestyle that are promoted by
      western governments lack such conclusive verification. Promotion of
healthy eating through a low-fat diet for the
      prevention of coronary heart disease is a case in point. Conventional
wisdom leads many people to believe that
      fruit plus vegetables plus oily fish plus semiskimmed milk plus all-bran
(and the list rolls depressingly on) equals
      health and wellbeing. But is such healthy eating going to have any effect?
 Probably not: some experts claim that
      the simple fat-reducing diets can produce only marginal reductions in
blood cholesterol concentrations. They claim
      that much more drastic diets which, even with the best will in the world,
would be impossible for most of us to
      sustain, are needed to achieve target cholesterol reductions that would
affect coronary heart disease.

      Fitzpatrick quotes David Weatherall's assertion that "It is unpardonable
to try to alter the diet of an entire
      population without sufficient information". Fitzpatrick uses well
researched objective analyses of all the major
      health promotion campaigns, from alcohol to exercise, to convince this
reader that health promotion should not
      continue to go unquestioned.

      But dissecting the science behind the healthy lifestyle is not
Fitzpatrick's main concern. As a general practitioner,
      he is conscious of the impact of such government intervention on the whole
 practice of medicine, and claims that
      such continued intervention diminishes the autonomy of patients. With the
shift to a more proactive approach to
      health, he questions the role of physicians who are continuously advised
to seize the opportunity when patients
      walk into the surgery to inform them about the dangers of their
lifestyles, thus taking a more social and political
      role in patients' lives. Instead of serving the needs of patients, says
Fitzpatrick, general practitioners "now serve
      the demands of government policy and the dictates of government-imposed
health promotion performance
      targets". In this way patients are transformed from individuals seeking
medical treatment to the object of medical
      intervention. Fitzpatrick goes so far as to ask whether health has become
the new religion, in which "activities
      once presribed as sinful--gluttony, sloth, lust--are now regulated in the
name of health". Fitzpatrick's reaction is
      controversial and blunt, yet his investigations are thorough and
persuasive. The Tyranny of Health highlights the
      importance of being aware of such professsional regulation over our
personal lives and of the need to separate
      medicine from politics. With doctors under increasing public scrutiny and
regulation, it is more important than ever
      for doctors and patients to question such regulation, and for doctors to
focus on treating the sick and leaving the
      well alone. With an ever-growing elderly population that still remains
largely neglected, a major shift in the UK
      government's priorities cannot, for some, come soon enough.

Sally Hargreaves
The Lancet, London, UK

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